ALL-PAYER HEALTH CARE PAYMENT

Illinois General Assembly - Full Text of SB3900

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
SB3900

Introduced 2/6/2026, by Sen. Lakesia Collins

SYNOPSIS AS INTRODUCED:

New Act
5 ILCS 100/5-5

from Ch. 127, par. 1005-5
210 ILCS 85/6.25
215 ILCS 5/370c

from Ch. 73, par. 982c
215 ILCS 125/4-2

from Ch. 111 1/2, par. 1408.2
305 ILCS 5/5-5

Creates the Illinois All-Payer Health Care Payment and Global Budget
Act. Creates the Illinois Health Care Cost and Payment Board as an
independent body within the Department of Healthcare and Family Services
and sets forth its membership and powers. Defines "commercial payer" as
any health insurance issuer, health maintenance organization, or
third-party administrator subject to regulation by the Illinois Department
of Insurance, excluding self-funded plans governed solely by ERISA.
Provides that all commercial payers shall reimburse hospitals for covered
services at standardized rates established by the Board. Defines "global
hospital budget" as a prospective, fixed annual operating revenue amount
established for a hospital to cover all inpatient and outpatient hospital
services. Provides that the Board shall establish prospective annual
global hospital budgets for Illinois hospitals. Provides that the Board
shall establish a unified health care data system in coordination with
State agencies. Creates the Health Care Payment Reform Advisory Council to
advise the Board. Provides that the Governor, in consultation with the
Board, shall seek all necessary federal approvals, including Medicare
demonstrations and Medicaid waivers, to implement the Act. Amends the
Illinois Administrative Procedure Act, Hospital Licensing Act, Illinois
Insurance Code, Health Maintenance Organization Act, and Illinois Public
Aid Code with regard to the new Act. Contains a severability clause.
Effective immediately.
LRB104 20577 SSS 34064 b

A BILL FOR

SB3900
LRB104 20577 SSS 34064 b
1

AN ACT concerning health.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 1.
Short title.
This Act may be cited as the
5
Illinois All-Payer Health Care Payment and Global Budget Act.

6

Section 3.
Legislative findings and purposes.
7

(a) The General Assembly finds that:
8

(1) Health care expenditures in Illinois continue to
9

grow at a rate that is unsustainable for households,
10

employers, and the State.
11

(2) Fragmented payment systems and differential
12

reimbursement rates contribute to cost-shifting,
13

administrative waste, and inequitable access to care.
14

(3) Hospitals and essential providers require
15

predictable and stable financing to meet community health
16

needs, particularly in rural and safety-net settings.
17

(4) States may, consistent with federal law and
18

through approved waivers and demonstrations, align
19

Medicare, Medicaid, and commercial payment systems.
20

(b) The purposes of this Act are to:
21

(1) Establish an all-payer health care payment system
22

with standardized reimbursement rates across hospital
23

systems;

SB3900
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1

(2) Implement prospective global hospital budgets that
2

are decoupled from service volume;
3

(3) Control the growth of total health care
4

expenditures while maintaining or improving quality,
5

access, and equity;
6

(4) Reduce administrative burden and eliminate
7

cost-shifting among payers; and
8

(5) Support a stable and sustainable health care
9

workforce.

10

Section 5.
Definitions.
As used in this Act:
11

"All-payer payment system" means a system under which
12
reimbursement rates and payment methodologies are standardized
13
and applied uniformly across all participating payers.
14

"Board" means the Illinois Health Care Cost and Payment
15
Board established under Section 10.
16

"Commercial payer" means any health insurance issuer,
17
health maintenance organization, or third-party administrator
18
subject to regulation by the Illinois Department of Insurance,
19
excluding self-funded plans governed solely by ERISA.
20

"Global hospital budget" means a prospective, fixed annual
21
operating revenue amount established for a hospital to cover
22
all inpatient and outpatient hospital services.
23

"Hospital" means any facility licensed under the Hospital
24
Licensing Act.

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Section 10.
Illinois Health Care Cost and Payment Board.
2

(a) The Illinois Health Care Cost and Payment Board is
3
created as an independent body within the Department of
4
Healthcare and Family Services.
5

(b) The Board shall consist of 9 members appointed by the
6
Governor with the advice and consent of the Senate, including
7
individuals with expertise in health economics, hospital
8
administration, clinical care, labor, consumer advocacy, and
9
health equity. No more than 4 members shall have current
10
financial ties to health care entities regulated under this
11
Act.
12

(c) The Board has the authority to:
13

(1) Establish and administer an all-payer payment
14

system;
15

(2) Set standardized reimbursement rates and
16

methodologies;
17

(3) Establish, approve, and enforce global hospital
18

budgets;
19

(4) Set statewide total cost of care growth targets;
20

(5) Collect data and require reporting necessary to
21

carry out this Act; and
22

(6) Enforce compliance through audits, corrective
23

actions, and penalties.

24

Section 15.
All-payer standardized reimbursement rates.
25

(a) Beginning January 1, 2027, all commercial payers shall

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1
reimburse hospitals for covered services at standardized rates
2
established by the Board.
3

(b) Standardized rates shall:
4

(1) Be based on a transparent benchmark, including the
5

Medicare fee schedule or diagnosis-related group system;
6

(2) Apply uniformly across commercial payers for the
7

same service within a defined geographic region;
8

(3) Include adjustments approved by the Board for:
9

(A) Patient acuity;
10

(B) Teaching status;
11

(C) Rural or safety-net designation; and
12

(D) Documented social risk factors.
13

(c) A commercial payer or hospital shall not charge, pay,
14
or collect amounts in excess of the standardized rate.
15

(d) Nothing in this Section shall be construed to reduce
16
covered benefits under Medicare or Medicaid. Medicaid
17
participation shall be aligned through federal waivers or
18
State plan amendments.

19

Section 20.
Global hospital budgets.
20

(a) The Board shall establish prospective annual global
21
hospital budgets for hospitals licensed in Illinois.
22

(b) Global hospital budgets shall:
23

(1) Cover all inpatient and outpatient hospital
24

services;
25

(2) Be determined using:

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(A) Historical utilization and spending;
2

(B) Community health needs assessments;
3

(C) Population size and demographics; and
4

(D) Quality, access, and equity performance; and
5

(3) Be adjusted annually for inflation, population
6

change, and policy priorities.
7

(c) By State fiscal year 2028, the Board shall implement
8
global hospital budgets for at least 5 hospitals representing
9
diverse geographic regions.
10

(d) By State fiscal year 2031, all hospitals shall operate
11
under global hospital budgets, except critical access
12
hospitals, which may elect to participate.
13

(e) A hospital operating under a global budget shall not
14
increase total annual revenue through increased service
15
volume.

16

Section 25.
Budget submission and review.
17

(a) Each hospital subject to this Act shall submit an
18
annual budget proposal to the Board in a form prescribed by the
19
Board.
20

(b) The Board shall review proposed budgets to ensure:
21

(1) Alignment with statewide total cost of care growth
22

targets;
23

(2) Maintenance of access to essential services; and
24

(3) Compliance with quality and equity standards.
25

(c) The Board may approve, modify, or reject a proposed

SB3900
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1
budget after public notice and comment.

2

Section 30.
Enforcement and penalties.
3

(a) The Board may conduct audits and require production of
4
documents.
5

(b) For noncompliance, the Board may impose:
6

(1) Financial penalties;
7

(2) Budget reductions;
8

(3) Corrective action plans; and
9

(4) Referral to the Department of Insurance or the
10

Attorney General.

11

Section 35.
Data collection and transparency.
12

(a) The Board shall establish a unified health care data
13
system in coordination with State agencies.
14

(b) Data shall be used to monitor:
15

(1) Total cost of care;
16

(2) Utilization and access; and
17

(3) Quality and equity outcomes.

18

Section 40.
Health Care Payment Reform Advisory Council.
19

(a) A Health Care Payment Reform Advisory Council is
20
created to advise the Board.
21

(b) Membership shall include representatives of hospitals,
22
physicians, nurses, labor organizations, consumers, insurers,
23
Medicaid managed care organizations, and rural providers.

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Section 45.
Federal waivers and alignment.
The Governor,
2
in consultation with the Board, shall seek all necessary
3
federal approvals, including Medicare demonstrations and
4
Medicaid waivers, to implement this Act.

5

Section 81.
The Illinois Administrative Procedure Act is
6
amended by changing Section 5-5 as follows:

7

(5 ILCS 100/5-5)

(from Ch. 127, par. 1005-5)
8

Sec. 5-5.
Applicability.
All rules of agencies shall be
9
adopted in accordance with this Article.
10

The Illinois Health Care Cost and Payment Board shall be
11
exempt from rulemaking requirements under this Section for the
12
establishment of initial standardized reimbursement rates and
13
global hospital budgets; provided that subsequent revisions
14
shall be subject to public notice and comment.

15
(Source: P.A. 87-823.)

16

Section 83.
The Hospital Licensing Act is amended by
17
changing Section 6.25 as follows:

18

(210 ILCS 85/6.25)
19

Sec. 6.25.
Safe patient handling policy.
20

(a) In this Section:
21

"Health care worker" means an individual providing direct

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1
patient care services who may be required to lift, transfer,
2
reposition, or move a patient.
3

"Nurse" means an advanced practice registered nurse, a
4
registered nurse, or a licensed practical nurse licensed under
5
the Nurse Practice Act.
6

"Safe lifting equipment and accessories" means mechanical
7
equipment designed to lift, move, reposition, and transfer
8
patients, including, but not limited to, fixed and portable
9
ceiling lifts, sit-to-stand lifts, slide sheets and boards,
10
slings, and repositioning and turning sheets.
11

"Safe lifting team" means at least 2 individuals who are
12
trained in the use of both safe lifting techniques and safe
13
lifting equipment and accessories, including the
14
responsibility for knowing the location and condition of such
15
equipment and accessories.
16

(b) A hospital must adopt and ensure implementation of a
17
policy to identify, assess, and develop strategies to control
18
risk of injury to patients and nurses and other health care
19
workers associated with the lifting, transferring,
20
repositioning, or movement of a patient. The policy shall
21
establish a process that, at a minimum, includes all of the
22
following:
23

(1) Analysis of the risk of injury to patients and
24

nurses and other health care workers posted by the patient
25

handling needs of the patient populations served by the
26

hospital and the physical environment in which the patient

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handling and movement occurs.
2

(2) Education and training of nurses and other direct
3

patient care providers in the identification, assessment,
4

and control of risks of injury to patients and nurses and
5

other health care workers during patient handling and on
6

safe lifting policies and techniques and current lifting
7

equipment.
8

(3) Evaluation of alternative ways to reduce risks
9

associated with patient handling, including evaluation of
10

equipment and the environment.
11

(4) Restriction, to the extent feasible with existing
12

equipment and aids, of manual patient handling or movement
13

of all or most of a patient's weight except for emergency,
14

life-threatening, or otherwise exceptional circumstances.
15

(5) Collaboration with and an annual report to the
16

nurse staffing committee.
17

(6) Procedures for a nurse to refuse to perform or be
18

involved in patient handling or movement that the nurse in
19

good faith believes will expose a patient or nurse or
20

other health care worker to an unacceptable risk of
21

injury.
22

(7) Submission of an annual report to the hospital's
23

governing body or quality assurance committee on
24

activities related to the identification, assessment, and
25

development of strategies to control risk of injury to
26

patients and nurses and other health care workers

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associated with the lifting, transferring, repositioning,
2

or movement of a patient.
3

(8) In developing architectural plans for construction
4

or remodeling of a hospital or unit of a hospital in which
5

patient handling and movement occurs, consideration of the
6

feasibility of incorporating patient handling equipment or
7

the physical space and construction design needed to
8

incorporate that equipment.
9

(9) Fostering and maintaining patient safety, dignity,
10

self-determination, and choice, including the following
11

policies, strategies, and procedures:
12

(A) the existence and availability of a trained
13

safe lifting team;
14

(B) a policy of advising patients of a range of
15

transfer and lift options, including adjustable
16

diagnostic and treatment equipment, mechanical lifts,
17

and provision of a trained safe lifting team;
18

(C) the right of a competent patient, or guardian
19

of a patient adjudicated incompetent, to choose among
20

the range of transfer and lift options, subject to the
21

provisions of subparagraph (E) of this paragraph (9);
22

(D) procedures for documenting, upon admission and
23

as status changes, a mobility assessment and plan for
24

lifting, transferring, repositioning, or movement of a
25

patient, including the choice of the patient or
26

patient's guardian among the range of transfer and

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1

lift options; and
2

(E) incorporation of such safe lifting procedures,
3

techniques, and equipment as are consistent with
4

applicable federal law.
5

(c) A hospital licensed under this Act that is subject to a
6
global hospital budget established by the Illinois Health Care
7
Cost and Payment Board shall operate in compliance with such
8
budget as a condition of licensure.

9
(Source: P.A. 100-513, eff. 1-1-18
.)

10

Section 85.
The Illinois Insurance Code is amended by
11
changing Section 370c as follows:

12

(215 ILCS 5/370c)

(from Ch. 73, par. 982c)
13

Sec. 370c.
Mental and emotional disorders.
14

(a)(1) On and after January 1, 2022 (the effective date of
15
Public Act 102-579), every insurer that amends, delivers,
16
issues, or renews group accident and health policies providing
17
coverage for hospital or medical treatment or services for
18
illness shall provide coverage for the medically necessary
19
treatment of mental, emotional, nervous, or substance use
20
disorders or conditions consistent with the parity
21
requirements of Section 370c.1 of this Code.
22

(2) Each insured that is covered for mental, emotional,
23
nervous, or substance use disorders or conditions shall be
24
free to select the physician licensed to practice medicine in

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all its branches, licensed clinical psychologist, licensed
2
clinical social worker, licensed clinical professional
3
counselor, licensed marriage and family therapist, licensed
4
speech-language pathologist, or other licensed or certified
5
professional at a program licensed pursuant to the Substance
6
Use Disorder Act of his or her choice to treat such disorders,
7
and the insurer shall pay the covered charges of such
8
physician licensed to practice medicine in all its branches,
9
licensed clinical psychologist, licensed clinical social
10
worker, licensed clinical professional counselor, licensed
11
marriage and family therapist, licensed speech-language
12
pathologist, or other licensed or certified professional at a
13
program licensed pursuant to the Substance Use Disorder Act up
14
to the limits of coverage, provided (i) the disorder or
15
condition treated is covered by the policy, and (ii) the
16
physician, licensed psychologist, licensed clinical social
17
worker, licensed clinical professional counselor, licensed
18
marriage and family therapist, licensed speech-language
19
pathologist, or other licensed or certified professional at a
20
program licensed pursuant to the Substance Use Disorder Act is
21
authorized to provide said services under the statutes of this
22
State and in accordance with accepted principles of his or her
23
profession.
24

(3) Insofar as this Section applies solely to licensed
25
clinical social workers, licensed clinical professional
26
counselors, licensed marriage and family therapists, licensed

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1
speech-language pathologists, and other licensed or certified
2
professionals at programs licensed pursuant to the Substance
3
Use Disorder Act, those persons who may provide services to
4
individuals shall do so after the licensed clinical social
5
worker, licensed clinical professional counselor, licensed
6
marriage and family therapist, licensed speech-language
7
pathologist, or other licensed or certified professional at a
8
program licensed pursuant to the Substance Use Disorder Act
9
has informed the patient of the desirability of the patient
10
conferring with the patient's primary care physician.
11

(4) "Mental, emotional, nervous, or substance use disorder
12
or condition" means a condition or disorder that involves a
13
mental health condition or substance use disorder that falls
14
under any of the diagnostic categories listed in the mental
15
and behavioral disorders chapter of the current edition of the
16
World Health Organization's International Classification of
17
Disease or that is listed in the most recent version of the
18
American Psychiatric Association's Diagnostic and Statistical
19
Manual of Mental Disorders. "Mental, emotional, nervous, or
20
substance use disorder or condition" includes any mental
21
health condition that occurs during pregnancy or during the
22
postpartum period and includes, but is not limited to,
23
postpartum depression.
24

(5) Medically necessary treatment and medical necessity
25
determinations shall be interpreted and made in a manner that
26
is consistent with and pursuant to subsections (h) through

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1
(y).
2

(b)(1) (Blank).
3

(2) (Blank).
4

(2.5) (Blank).
5

(3) Unless otherwise prohibited by federal law and
6
consistent with the parity requirements of Section 370c.1 of
7
this Code, the insurer that amends, delivers, issues, or
8
renews a group or individual policy of accident and health
9
insurance, a qualified health plan offered through the health
10
insurance marketplace, or a provider of treatment of mental,
11
emotional, nervous, or substance use disorders or conditions
12
shall furnish medical records or other necessary data that
13
substantiate that initial or continued treatment is at all
14
times medically necessary. Nothing in this paragraph (3)
15
supersedes the prohibition on prior authorization requirements
16
to the extent provided under subsections (g) and (w) and
17
subparagraph (A) of paragraph (6.5) of this subsection.
18
Nothing prevents the insured from agreeing in writing to
19
continue treatment at his or her expense. When making a
20
determination of the medical necessity for a treatment
21
modality for mental, emotional, nervous, or substance use
22
disorders or conditions, an insurer must make the
23
determination in a manner that is consistent with the manner
24
used to make that determination with respect to other diseases
25
or illnesses covered under the policy, including an appeals
26
process. Medical necessity determinations for substance use

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1
disorders shall be made in accordance with appropriate patient
2
placement criteria established by the American Society of
3
Addiction Medicine. No additional criteria may be used to make
4
medical necessity determinations for substance use disorders.
5

(4) A group health benefit plan amended, delivered,
6
issued, or renewed on or after January 1, 2019 (the effective
7
date of Public Act 100-1024) or an individual policy of
8
accident and health insurance or a qualified health plan
9
offered through the health insurance marketplace amended,
10
delivered, issued, or renewed on or after January 1, 2019 (the
11
effective date of Public Act 100-1024):
12

(A) shall provide coverage based upon medical
13

necessity for the treatment of a mental, emotional,
14

nervous, or substance use disorder or condition consistent
15

with the parity requirements of Section 370c.1 of this
16

Code; provided, however, that in each calendar year
17

coverage shall not be less than the following:
18

(i) 45 days of inpatient treatment; and
19

(ii) beginning on June 26, 2006 (the effective
20

date of Public Act 94-921), 60 visits for outpatient
21

treatment including group and individual outpatient
22

treatment; and
23

(iii) for plans or policies delivered, issued for
24

delivery, renewed, or modified after January 1, 2007
25

(the effective date of Public Act 94-906), 20
26

additional outpatient visits for speech therapy for

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treatment of pervasive developmental disorders that
2

will be in addition to speech therapy provided
3

pursuant to item (ii) of this subparagraph (A); and
4

(B) may not include a lifetime limit on the number of
5

days of inpatient treatment or the number of outpatient
6

visits covered under the plan.
7

(C) (Blank).
8

(5) An issuer of a group health benefit plan or an
9
individual policy of accident and health insurance or a
10
qualified health plan offered through the health insurance
11
marketplace may not count toward the number of outpatient
12
visits required to be covered under this Section an outpatient
13
visit for the purpose of medication management and shall cover
14
the outpatient visits under the same terms and conditions as
15
it covers outpatient visits for the treatment of physical
16
illness.
17

(5.5) An individual or group health benefit plan amended,
18
delivered, issued, or renewed on or after September 9, 2015
19
(the effective date of Public Act 99-480) shall offer coverage
20
for medically necessary acute treatment services and medically
21
necessary clinical stabilization services. The treating
22
provider shall base all treatment recommendations and the
23
health benefit plan shall base all medical necessity
24
determinations for substance use disorders in accordance with
25
the most current edition of the Treatment Criteria for
26
Addictive, Substance-Related, and Co-Occurring Conditions

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1
established by the American Society of Addiction Medicine. The
2
treating provider shall base all treatment recommendations and
3
the health benefit plan shall base all medical necessity
4
determinations for medication-assisted treatment in accordance
5
with the most current Treatment Criteria for Addictive,
6
Substance-Related, and Co-Occurring Conditions established by
7
the American Society of Addiction Medicine.
8

As used in this subsection:
9

"Acute treatment services" means 24-hour medically
10
supervised addiction treatment that provides evaluation and
11
withdrawal management and may include biopsychosocial
12
assessment, individual and group counseling, psychoeducational
13
groups, and discharge planning.
14

"Clinical stabilization services" means 24-hour treatment,
15
usually following acute treatment services for substance
16
abuse, which may include intensive education and counseling
17
regarding the nature of addiction and its consequences,
18
relapse prevention, outreach to families and significant
19
others, and aftercare planning for individuals beginning to
20
engage in recovery from addiction.
21

"Prior authorization" has the meaning given to that term
22
in Section 15 of the Prior Authorization Reform Act.
23

(6) An issuer of a group health benefit plan may provide or
24
offer coverage required under this Section through a managed
25
care plan.
26

(6.5) An individual or group health benefit plan amended,

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1
delivered, issued, or renewed on or after January 1, 2019 (the
2
effective date of Public Act 100-1024):
3

(A) shall not impose prior authorization requirements,
4

including limitations on dosage, other than those
5

established under the Treatment Criteria for Addictive,
6

Substance-Related, and Co-Occurring Conditions
7

established by the American Society of Addiction Medicine,
8

on a prescription medication approved by the United States
9

Food and Drug Administration that is prescribed or
10

administered for the treatment of substance use disorders;
11

(B) shall not impose any step therapy requirements;
12

(C) shall place all prescription medications approved
13

by the United States Food and Drug Administration
14

prescribed or administered for the treatment of substance
15

use disorders on, for brand medications, the lowest tier
16

of the drug formulary developed and maintained by the
17

individual or group health benefit plan that covers brand
18

medications and, for generic medications, the lowest tier
19

of the drug formulary developed and maintained by the
20

individual or group health benefit plan that covers
21

generic medications; and
22

(D) shall not exclude coverage for a prescription
23

medication approved by the United States Food and Drug
24

Administration for the treatment of substance use
25

disorders and any associated counseling or wraparound
26

services on the grounds that such medications and services

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LRB104 20577 SSS 34064 b
1

were court ordered.
2

(7) (Blank).
3

(8) (Blank).
4

(9) With respect to all mental, emotional, nervous, or
5
substance use disorders or conditions, coverage for inpatient
6
treatment shall include coverage for treatment in a
7
residential treatment center certified or licensed by the
8
Department of Public Health or the Department of Human
9
Services.
10

(c) This Section shall not be interpreted to require
11
coverage for speech therapy or other habilitative services for
12
those individuals covered under Section 356z.15 of this Code.
13

(d) With respect to a group or individual policy of
14
accident and health insurance or a qualified health plan
15
offered through the health insurance marketplace, the
16
Department and, with respect to medical assistance, the
17
Department of Healthcare and Family Services shall each
18
enforce the requirements of this Section and Sections 356z.23
19
and 370c.1 of this Code, the Paul Wellstone and Pete Domenici
20
Mental Health Parity and Addiction Equity Act of 2008, 42
21
U.S.C. 18031(j), and any amendments to, and federal guidance
22
or regulations issued under, those Acts, including, but not
23
limited to, final regulations issued under the Paul Wellstone
24
and Pete Domenici Mental Health Parity and Addiction Equity
25
Act of 2008 and final regulations applying the Paul Wellstone
26
and Pete Domenici Mental Health Parity and Addiction Equity

SB3900
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LRB104 20577 SSS 34064 b
1
Act of 2008 to Medicaid managed care organizations, the
2
Children's Health Insurance Program, and alternative benefit
3
plans. Specifically, the Department and the Department of
4
Healthcare and Family Services shall take action:
5

(1) proactively ensuring compliance by individual and
6

group policies, including by requiring that insurers
7

submit comparative analyses, as set forth in paragraph (6)
8

of subsection (k) of Section 370c.1, demonstrating how
9

they design and apply nonquantitative treatment
10

limitations, both as written and in operation, for mental,
11

emotional, nervous, or substance use disorder or condition
12

benefits as compared to how they design and apply
13

nonquantitative treatment limitations, as written and in
14

operation, for medical and surgical benefits;
15

(2) evaluating all consumer or provider complaints
16

regarding mental, emotional, nervous, or substance use
17

disorder or condition coverage for possible parity
18

violations;
19

(3) performing parity compliance market conduct
20

examinations or, in the case of the Department of
21

Healthcare and Family Services, parity compliance audits
22

of individual and group plans and policies, including, but
23

not limited to, reviews of:
24

(A) nonquantitative treatment limitations,
25

including, but not limited to, prior authorization
26

requirements, concurrent review, retrospective review,

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1

step therapy, network admission standards,
2

reimbursement rates, and geographic restrictions;
3

(B) denials of authorization, payment, and
4

coverage; and
5

(C) other specific criteria as may be determined
6

by the Department.
7

The findings and the conclusions of the parity compliance
8
market conduct examinations and audits shall be made public.
9

The Director may adopt rules to effectuate any provisions
10
of the Paul Wellstone and Pete Domenici Mental Health Parity
11
and Addiction Equity Act of 2008 that relate to the business of
12
insurance.
13

(e) Availability of plan information.
14

(1) The criteria for medical necessity determinations
15

made under a group health plan, an individual policy of
16

accident and health insurance, or a qualified health plan
17

offered through the health insurance marketplace with
18

respect to mental health or substance use disorder
19

benefits (or health insurance coverage offered in
20

connection with the plan with respect to such benefits)
21

must be made available by the plan administrator (or the
22

health insurance issuer offering such coverage) to any
23

current or potential participant, beneficiary, or
24

contracting provider upon request.
25

(2) The reason for any denial under a group health
26

benefit plan, an individual policy of accident and health

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LRB104 20577 SSS 34064 b
1

insurance, or a qualified health plan offered through the
2

health insurance marketplace (or health insurance coverage
3

offered in connection with such plan or policy) of
4

reimbursement or payment for services with respect to
5

mental, emotional, nervous, or substance use disorders or
6

conditions benefits in the case of any participant or
7

beneficiary must be made available within a reasonable
8

time and in a reasonable manner and in readily
9

understandable language by the plan administrator (or the
10

health insurance issuer offering such coverage) to the
11

participant or beneficiary upon request.
12

(f) As used in this Section, "group policy of accident and
13
health insurance" and "group health benefit plan" includes (1)
14
State-regulated employer-sponsored group health insurance
15
plans written in Illinois or which purport to provide coverage
16
for a resident of this State; and (2) State, county,
17
municipal, or school district employee health plans.
18
References to an insurer include all plans described in this
19
subsection.
20

(g) (1) As used in this subsection:
21

"Benefits", with respect to insurers that are not Medicaid
22
managed care organizations, means the benefits provided for
23
treatment services for inpatient and outpatient treatment of
24
substance use disorders or conditions at American Society of
25
Addiction Medicine levels of treatment 2.1 (Intensive
26
Outpatient), 2.5 (High-Intensity Outpatient), 3.1 (Clinically

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1
Managed Low-Intensity Residential), 3.5 (Clinically Managed
2
High-Intensity Residential), and 3.7 (Medically Managed
3
Residential) and OMT (Opioid Maintenance Therapy) services.
4

"Benefits", with respect to Medicaid managed care
5
organizations, means the benefits provided for treatment
6
services for inpatient and outpatient treatment of substance
7
use disorders or conditions at American Society of Addiction
8
Medicine levels of treatment 2.1 (Intensive Outpatient), 2.5
9
(High-Intensity Outpatient), 3.5 (Clinically Managed
10
High-Intensity Residential), and 3.7 (Medically Managed
11
Residential) and OMT (Opioid Maintenance Therapy) services.
12

"Substance use disorder treatment provider or facility"
13
means a licensed physician, licensed psychologist, licensed
14
psychiatrist, licensed advanced practice registered nurse, or
15
licensed, certified, or otherwise State-approved facility or
16
provider of substance use disorder treatment.
17

(2) A group health insurance policy, an individual health
18
benefit plan, or qualified health plan that is offered through
19
the health insurance marketplace, small employer group health
20
plan, and large employer group health plan that is amended,
21
delivered, issued, executed, or renewed in this State, or
22
approved for issuance or renewal in this State, on or after
23
January 1, 2019 (the effective date of Public Act 100-1023)
24
shall comply with the requirements of this Section and Section
25
370c.1. The services for the treatment and the ongoing
26
assessment of the patient's progress in treatment shall follow

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1
the requirements of 77 Ill. Adm. Code 2060.
2

(3) Prior authorization shall not be utilized for the
3
benefits under this subsection. Except to the extent
4
prohibited by Section 370c.1 with respect to treatment
5
limitations in a benefit classification or subclassification,
6
the insurer may require the substance use disorder treatment
7
provider or facility to notify the insurer of the initiation
8
of treatment. For an insurer that is not a Medicaid managed
9
care organization, the substance use disorder treatment
10
provider or facility may be required to give notification for
11
the initiation of treatment of the covered person within 2
12
business days. For Medicaid managed care organizations, the
13
substance use disorder treatment provider or facility may be
14
required to give notification in accordance with the protocol
15
set forth in the provider agreement for initiation of
16
treatment within 24 hours. If the Medicaid managed care
17
organization is not capable of accepting the notification in
18
accordance with the contractual protocol during the 24-hour
19
period following admission, the substance use disorder
20
treatment provider or facility shall have one additional
21
business day to provide the notification to the appropriate
22
managed care organization. Treatment plans shall be developed
23
in accordance with the requirements and timeframes established
24
in 77 Ill. Adm. Code 2060. No such coverage shall be subject to
25
concurrent review prior to the applicable notification
26
deadline. If coverage is denied retrospectively, neither the

SB3900
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LRB104 20577 SSS 34064 b
1
provider or facility nor the insurer shall bill, and the
2
covered individual shall not be liable, for any treatment
3
under this subsection through the date the adverse
4
determination is issued, other than any copayment,
5
coinsurance, or deductible for the treatment or stay through
6
that date as applicable under the policy. Coverage shall not
7
be retrospectively denied for benefits that were furnished at
8
a participating substance use disorder facility prior to the
9
applicable notification deadline except for the following:
10

(A) upon reasonable determination that the benefits
11

were not provided;
12

(B) upon determination that the patient receiving the
13

treatment was not an insured, enrollee, or beneficiary
14

under the policy;
15

(C) upon material misrepresentation by the patient or
16

provider. As used in this subparagraph (C), "material"
17

means a fact or situation that is not merely technical in
18

nature and results or could result in a substantial change
19

in the situation;
20

(D) upon determination that a service was excluded
21

under the terms of coverage. For situations that qualify
22

under this subparagraph (D), the limitation to billing for
23

a copayment, coinsurance, or deductible shall not apply;
24

(E) upon determination that a service was not
25

medically necessary consistent with subsections (h)
26

through (n); or

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LRB104 20577 SSS 34064 b
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(F) upon determination that the patient did not
2

consent to the treatment and that there was no court order
3

mandating the treatment.
4

(4) For an insurer that is not a Medicaid managed care
5
organization, if an insurer determines that benefits are no
6
longer medically necessary, the insurer shall notify the
7
covered person, the covered person's authorized
8
representative, if any, and the covered person's health care
9
provider in writing of the covered person's right to request
10
an external review pursuant to the Health Carrier External
11
Review Act. The notification shall occur within 24 hours
12
following the adverse determination.
13

Pursuant to the requirements of the Health Carrier
14
External Review Act, the covered person or the covered
15
person's authorized representative may request an expedited
16
external review. An expedited external review may not occur if
17
the substance use disorder treatment provider or facility
18
determines that continued treatment is no longer medically
19
necessary.
20

If an expedited external review request meets the criteria
21
of the Health Carrier External Review Act, an independent
22
review organization shall make a final determination of
23
medical necessity within 72 hours. If an independent review
24
organization upholds an adverse determination, an insurer
25
shall remain responsible to provide coverage of benefits
26
through the day following the determination of the independent

SB3900
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LRB104 20577 SSS 34064 b
1
review organization. A decision to reverse an adverse
2
determination shall comply with the Health Carrier External
3
Review Act.
4

(5) The substance use disorder treatment provider or
5
facility shall provide the insurer with 7 business days'
6
advance notice of the planned discharge of the patient from
7
the substance use disorder treatment provider or facility and
8
notice on the day that the patient is discharged from the
9
substance use disorder treatment provider or facility.
10

(6) The benefits required by this subsection shall be
11
provided to all covered persons with a diagnosis of substance
12
use disorder or conditions. The presence of additional related
13
or unrelated diagnoses shall not be a basis to reduce or deny
14
the benefits required by this subsection.
15

(7) Nothing in this subsection shall be construed to
16
require an insurer to provide coverage for any of the benefits
17
in this subsection.
18

(8) Any concurrent or retrospective review permitted by
19
this subsection must be consistent with the utilization review
20
provisions in subsections (h) through (n).
21

(h) As used in this Section:
22

"Generally accepted standards of mental, emotional,
23
nervous, or substance use disorder or condition care" means
24
standards of care and clinical practice that are generally
25
recognized by health care providers practicing in relevant
26
clinical specialties such as psychiatry, psychology, clinical

SB3900
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LRB104 20577 SSS 34064 b
1
sociology, social work, addiction medicine and counseling, and
2
behavioral health treatment. Valid, evidence-based sources
3
reflecting generally accepted standards of mental, emotional,
4
nervous, or substance use disorder or condition care include
5
peer-reviewed scientific studies and medical literature,
6
recommendations of nonprofit health care provider professional
7
associations and specialty societies, including, but not
8
limited to, patient placement criteria and clinical practice
9
guidelines, recommendations of federal government agencies,
10
and drug labeling approved by the United States Food and Drug
11
Administration.
12

"Medically necessary treatment of mental, emotional,
13
nervous, or substance use disorders or conditions" means a
14
service or product addressing the specific needs of that
15
patient, for the purpose of screening, preventing, diagnosing,
16
managing, or treating an illness, injury, or condition or its
17
symptoms and comorbidities, including minimizing the
18
progression of an illness, injury, or condition or its
19
symptoms and comorbidities in a manner that is all of the
20
following:
21

(1) in accordance with the generally accepted
22

standards of mental, emotional, nervous, or substance use
23

disorder or condition care;
24

(2) clinically appropriate in terms of type,
25

frequency, extent, site, and duration; and
26

(3) not primarily for the economic benefit of the

SB3900
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LRB104 20577 SSS 34064 b
1

insurer, purchaser, or for the convenience of the patient,
2

treating physician, or other health care provider.
3

"Utilization review" means either of the following:
4

(1) prospectively, retrospectively, or concurrently
5

reviewing and approving, modifying, delaying, or denying,
6

based in whole or in part on medical necessity, requests
7

by health care providers, insureds, or their authorized
8

representatives for coverage of health care services
9

before, retrospectively, or concurrently with the
10

provision of health care services to insureds.
11

(2) evaluating the medical necessity, appropriateness,
12

level of care, service intensity, efficacy, or efficiency
13

of health care services, benefits, procedures, or
14

settings, under any circumstances, to determine whether a
15

health care service or benefit subject to a medical
16

necessity coverage requirement in an insurance policy is
17

covered as medically necessary for an insured.
18

"Utilization review criteria" means patient placement
19
criteria or any criteria, standards, protocols, or guidelines
20
used by an insurer to conduct utilization review.
21

(i)(1) Every insurer that amends, delivers, issues, or
22
renews a group or individual policy of accident and health
23
insurance or a qualified health plan offered through the
24
health insurance marketplace in this State and Medicaid
25
managed care organizations providing coverage for hospital or
26
medical treatment on or after January 1, 2023 shall, pursuant

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LRB104 20577 SSS 34064 b
1
to subsections (h) through (s), provide coverage for medically
2
necessary treatment of mental, emotional, nervous, or
3
substance use disorders or conditions.
4

(2) An insurer shall not set a specific limit on the
5
duration of benefits or coverage of medically necessary
6
treatment of mental, emotional, nervous, or substance use
7
disorders or conditions or limit coverage only to alleviation
8
of the insured's current symptoms.
9

(3) All utilization review conducted by the insurer
10
concerning diagnosis, prevention, and treatment of insureds
11
diagnosed with mental, emotional, nervous, or substance use
12
disorders or conditions shall be conducted in accordance with
13
the requirements of subsections (k) through (w).
14

(4) An insurer that authorizes a specific type of
15
treatment by a provider pursuant to this Section shall not
16
rescind or modify the authorization after that provider
17
renders the health care service in good faith and pursuant to
18
this authorization for any reason, including, but not limited
19
to, the insurer's subsequent cancellation or modification of
20
the insured's or policyholder's contract, or the insured's or
21
policyholder's eligibility. Nothing in this Section shall
22
require the insurer to cover a treatment when the
23
authorization was granted based on a material
24
misrepresentation by the insured, the policyholder, or the
25
provider. Nothing in this Section shall require Medicaid
26
managed care organizations to pay for services if the

SB3900
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LRB104 20577 SSS 34064 b
1
individual was not eligible for Medicaid at the time the
2
service was rendered. Nothing in this Section shall require an
3
insurer to pay for services if the individual was not the
4
insurer's enrollee at the time services were rendered. As used
5
in this paragraph, "material" means a fact or situation that
6
is not merely technical in nature and results in or could
7
result in a substantial change in the situation.
8

(j) An insurer shall not limit benefits or coverage for
9
medically necessary services on the basis that those services
10
should be or could be covered by a public entitlement program,
11
including, but not limited to, special education or an
12
individualized education program, Medicaid, Medicare,
13
Supplemental Security Income, or Social Security Disability
14
Insurance, and shall not include or enforce a contract term
15
that excludes otherwise covered benefits on the basis that
16
those services should be or could be covered by a public
17
entitlement program. Nothing in this subsection shall be
18
construed to require an insurer to cover benefits that have
19
been authorized and provided for a covered person by a public
20
entitlement program. Medicaid managed care organizations are
21
not subject to this subsection.
22

(k) An insurer shall base any medical necessity
23
determination or the utilization review criteria that the
24
insurer, and any entity acting on the insurer's behalf,
25
applies to determine the medical necessity of health care
26
services and benefits for the diagnosis, prevention, and

SB3900
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LRB104 20577 SSS 34064 b
1
treatment of mental, emotional, nervous, or substance use
2
disorders or conditions on current generally accepted
3
standards of mental, emotional, nervous, or substance use
4
disorder or condition care. All denials and appeals shall be
5
reviewed by a professional with experience or expertise
6
comparable to the provider requesting the authorization.
7

(l) In conducting utilization review of all covered health
8
care services for the diagnosis, prevention, and treatment of
9
mental, emotional, and nervous disorders or conditions, an
10
insurer shall apply the criteria and guidelines set forth in
11
the most recent version of the treatment criteria developed by
12
an unaffiliated nonprofit professional association for the
13
relevant clinical specialty or, for Medicaid managed care
14
organizations, criteria and guidelines determined by the
15
Department of Healthcare and Family Services that are
16
consistent with generally accepted standards of mental,
17
emotional, nervous or substance use disorder or condition
18
care. Pursuant to subsection (b), in conducting utilization
19
review of all covered services and benefits for the diagnosis,
20
prevention, and treatment of substance use disorders an
21
insurer shall use the most recent edition of the patient
22
placement criteria established by the American Society of
23
Addiction Medicine.
24

(m) In conducting utilization review relating to level of
25
care placement, continued stay, transfer, discharge, or any
26
other patient care decisions that are within the scope of the

SB3900
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LRB104 20577 SSS 34064 b
1
sources specified in subsection (l), an insurer shall not
2
apply different, additional, conflicting, or more restrictive
3
utilization review criteria than the criteria set forth in
4
those sources. For all level of care placement decisions, the
5
insurer shall authorize placement at the level of care
6
consistent with the assessment of the insured using the
7
relevant patient placement criteria as specified in subsection
8
(l). If that level of placement is not available, the insurer
9
shall authorize the next higher level of care. In the event of
10
disagreement, the insurer shall provide full detail of its
11
assessment using the relevant criteria as specified in
12
subsection (l) to the provider of the service and the patient.
13

If an insurer purchases or licenses utilization review
14
criteria pursuant to this subsection, the insurer shall verify
15
and document before use that the criteria were developed in
16
accordance with subsection (k).
17

(n) In conducting utilization review that is outside the
18
scope of the criteria as specified in subsection (l) or
19
relates to the advancements in technology or in the types or
20
levels of care that are not addressed in the most recent
21
versions of the sources specified in subsection (l), an
22
insurer shall conduct utilization review in accordance with
23
subsection (k).
24

(o) This Section does not in any way limit the rights of a
25
patient under the Medical Patient Rights Act.
26

(p) This Section does not in any way limit early and

SB3900
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LRB104 20577 SSS 34064 b
1
periodic screening, diagnostic, and treatment benefits as
2
defined under 42 U.S.C. 1396d(r).
3

(q) To ensure the proper use of the criteria described in
4
subsection (l), every insurer shall do all of the following:
5

(1) Educate the insurer's staff, including any third
6

parties contracted with the insurer to review claims,
7

conduct utilization reviews, or make medical necessity
8

determinations about the utilization review criteria.
9

(2) Make the educational program available to other
10

stakeholders, including the insurer's participating or
11

contracted providers and potential participants,
12

beneficiaries, or covered lives. The education program
13

must be provided at least once a year, in-person or
14

digitally, or recordings of the education program must be
15

made available to the aforementioned stakeholders.
16

(3) Provide, at no cost, the utilization review
17

criteria and any training material or resources to
18

providers and insured patients upon request. For
19

utilization review criteria not concerning level of care
20

placement, continued stay, transfer, discharge, or other
21

patient care decisions used by the insurer pursuant to
22

subsection (m), the insurer may place the criteria on a
23

secure, password-protected website so long as the access
24

requirements of the website do not unreasonably restrict
25

access to insureds or their providers. No restrictions
26

shall be placed upon the insured's or treating provider's

SB3900
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LRB104 20577 SSS 34064 b
1

access right to utilization review criteria obtained under
2

this paragraph at any point in time, including before an
3

initial request for authorization.
4

(4) Track, identify, and analyze how the utilization
5

review criteria are used to certify care, deny care, and
6

support the appeals process.
7

(5) Conduct interrater reliability testing to ensure
8

consistency in utilization review decision making that
9

covers how medical necessity decisions are made; this
10

assessment shall cover all aspects of utilization review
11

as defined in subsection (h).
12

(6) Run interrater reliability reports about how the
13

clinical guidelines are used in conjunction with the
14

utilization review process and parity compliance
15

activities.
16

(7) Achieve interrater reliability pass rates of at
17

least 90% and, if this threshold is not met, immediately
18

provide for the remediation of poor interrater reliability
19

and interrater reliability testing for all new staff
20

before they can conduct utilization review without
21

supervision.
22

(8) Maintain documentation of interrater reliability
23

testing and the remediation actions taken for those with
24

pass rates lower than 90% and submit to the Department of
25

Insurance or, in the case of Medicaid managed care
26

organizations, the Department of Healthcare and Family

SB3900
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LRB104 20577 SSS 34064 b
1

Services the testing results and a summary of remedial
2

actions as part of parity compliance reporting set forth
3

in subsection (k) of Section 370c.1.
4

(r) This Section applies to all health care services and
5
benefits for the diagnosis, prevention, and treatment of
6
mental, emotional, nervous, or substance use disorders or
7
conditions covered by an insurance policy, including
8
prescription drugs.
9

(s) This Section applies to an insurer that amends,
10
delivers, issues, or renews a group or individual policy of
11
accident and health insurance or a qualified health plan
12
offered through the health insurance marketplace in this State
13
providing coverage for hospital or medical treatment and
14
conducts utilization review as defined in this Section,
15
including Medicaid managed care organizations, and any entity
16
or contracting provider that performs utilization review or
17
utilization management functions on an insurer's behalf.
18

(t) If the Director determines that an insurer has
19
violated this Section, the Director may, after appropriate
20
notice and opportunity for hearing, by order, assess a civil
21
penalty between $1,000 and $5,000 for each violation. Moneys
22
collected from penalties shall be deposited into the Parity
23
Advancement Fund established in subsection (i) of Section
24
370c.1.
25

(u) An insurer shall not adopt, impose, or enforce terms
26
in its policies or provider agreements, in writing or in

SB3900
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LRB104 20577 SSS 34064 b
1
operation, that undermine, alter, or conflict with the
2
requirements of this Section.
3

(v) The provisions of this Section are severable. If any
4
provision of this Section or its application is held invalid,
5
that invalidity shall not affect other provisions or
6
applications that can be given effect without the invalid
7
provision or application.
8

(w) Beginning January 1, 2026, coverage for medically
9
necessary treatment of mental, emotional, or nervous disorders
10
or conditions shall comply with the following requirements:
11

(1) No policy shall require prior authorization for
12

outpatient or partial hospitalization services for
13

treatment of mental, emotional, or nervous disorders or
14

conditions provided by a physician licensed to practice
15

medicine in all branches, a licensed clinical
16

psychologist, a licensed clinical social worker, a
17

licensed clinical professional counselor, a licensed
18

marriage and family therapist, a licensed speech-language
19

pathologist, or any other type of licensed, certified, or
20

legally authorized provider, including trainees working
21

under the supervision of a licensed health care
22

professional listed under this subsection, or facility
23

whose outpatient or partial hospitalization services the
24

policy covers for treatment of mental, emotional, or
25

nervous disorders or conditions. Such coverage may be
26

subject to concurrent and retrospective review consistent

SB3900
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1

with the utilization review provisions in subsections (h)
2

through (n) and Section 370c.1. Nothing in this paragraph
3

(1) supersedes a health maintenance organization's
4

referral requirement for services from nonparticipating
5

providers. An insurer may require providers or facilities
6

to notify the insurer of the initiation of treatment as
7

specified in this subsection, except to the extent
8

prohibited by Section 370c.1 with respect to treatment
9

limitations in a benefit classification or
10

subclassification. No such coverage shall be subject to
11

concurrent review for any services furnished before an
12

applicable notification deadline, subject to the
13

following:
14

(A) In the case of outpatient treatment, for an
15

insurer that is not a Medicaid managed care
16

organization, the insurer may set a notification
17

deadline of 2 business days after the initiation of
18

the covered person's treatment. A Medicaid managed
19

care organization may set a deadline of 24 hours after
20

the initiation of treatment. If the Medicaid managed
21

care organization is not capable of accepting the
22

notification in accordance with the contractual
23

protocol within the 24-hour period following
24

initiation, the treatment provider or facility shall
25

have one additional business day to provide the
26

notification to the Medicaid managed care

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1

organization.
2

(B) In the case of a partial hospitalization
3

program, for an insurer that is not a Medicaid managed
4

care organization, the insurer may set a notification
5

deadline of 48 hours after the initiation of the
6

covered person's treatment. A Medicaid managed care
7

organization may set a deadline of 24 hours after the
8

initiation of treatment. If the Medicaid managed care
9

organization is not capable of accepting the
10

notification in accordance with the contractual
11

protocol during the 24-hour period following
12

initiation, the treatment provider or facility shall
13

have one additional business day to provide the
14

notification to the Medicaid managed care
15

organization.
16

(2) No policy shall require prior authorization for
17

inpatient treatment at a hospital for mental, emotional,
18

or nervous disorders or conditions at a participating
19

provider. Additionally, no such coverage shall be subject
20

to concurrent review for the first 72 hours after
21

admission, provided that the provider must notify the
22

insurer of both the admission and the initial treatment
23

plan within 48 hours of admission. A discharge plan must
24

be fully developed and continuity services prepared to
25

meet the patient's needs and the patient's community
26

preference upon release. Recommended level of care

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placements identified in the discharge plan shall comply
2

with generally accepted standards of care, as defined in
3

subsection (h).
4

(A) If the provider satisfies the conditions of
5

paragraph (2), then the insurer shall approve coverage
6

of the recommended level of care, if applicable, upon
7

discharge subject to concurrent review.
8

(B) Nothing in this paragraph supersedes a health
9

maintenance organization's referral requirement for
10

services from nonparticipating providers upon a
11

patient's discharge from a hospital or facility.
12

(C) Concurrent review for such coverage must be
13

consistent with the utilization review provisions in
14

subsections (h) through (n).
15

(D) In this subsection, residential treatment that
16

is not otherwise identified in the discharge plan is
17

not inpatient hospitalization.
18

(3) Treatment provided under this subsection may be
19

reviewed retrospectively. If coverage is denied
20

retrospectively, neither the insurer nor the participating
21

provider shall bill, and the insured shall not be liable,
22

for any treatment under this subsection through the date
23

the adverse determination is issued, other than any
24

copayment, coinsurance, or deductible for the stay through
25

that date as applicable under the policy. Coverage shall
26

not be retrospectively denied for the first 72 hours of

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admission to inpatient hospitalization for treatment of
2

mental, emotional, or nervous disorders or conditions, or
3

before the applicable deadline under paragraph (1) of this
4

subsection for outpatient treatment or partial
5

hospitalization programs, at a participating provider
6

except:
7

(A) upon reasonable determination that the
8

inpatient mental health treatment was not provided;
9

(B) upon determination that the patient receiving
10

the treatment was not an insured, enrollee, or
11

beneficiary under the policy;
12

(C) upon material misrepresentation by the patient
13

or health care provider. In this item (C), "material"
14

means a fact or situation that is not merely technical
15

in nature and results or could result in a substantial
16

change in the situation;
17

(D) upon determination that a service was excluded
18

under the terms of coverage. In that case, the
19

limitation to billing for a copayment, coinsurance, or
20

deductible shall not apply;
21

(E) for outpatient treatment or partial
22

hospitalization programs only, upon determination that
23

a service was not medically necessary consistent with
24

subsections (h) through (n); or
25

(F) upon determination that the patient did not
26

consent to the treatment and that there was no court

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order mandating the treatment.
2

Nothing in this subsection shall be construed to
3

require a policy to cover any health care service excluded
4

under the terms of coverage.
5

This subsection does not apply to coverage for any
6

prescription or over-the-counter drug.
7

Nothing in this subsection shall be construed to
8

require the medical assistance program to reimburse for
9

services not covered by the medical assistance program as
10

authorized by the Illinois Public Aid Code or the
11

Children's Health Insurance Program Act.
12

(x) Notwithstanding any provision of this Section, nothing
13
shall require the medical assistance program under Article V
14
of the Illinois Public Aid Code or the Children's Health
15
Insurance Program Act to violate any applicable federal laws,
16
regulations, or grant requirements, including requirements for
17
utilization management, or any State or federal consent
18
decrees. Nothing in subsection (g) or (w) shall prevent the
19
Department of Healthcare and Family Services from requiring a
20
health care provider to use specified level of care,
21
admission, continued stay, or discharge criteria, including,
22
but not limited to, those under Section 5-5.23 of the Illinois
23
Public Aid Code, as long as the Department of Healthcare and
24
Family Services, subject to applicable federal laws,
25
regulations, or grant requirements, including requirements for
26
utilization management, does not require a health care

SB3900
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LRB104 20577 SSS 34064 b
1
provider to seek prior authorization or concurrent review from
2
the Department of Healthcare and Family Services, a Medicaid
3
managed care organization, or a utilization review
4
organization under the circumstances expressly prohibited by
5
subsections (g) and (w). Nothing in this Section prohibits a
6
health plan, including a Medicaid managed care organization,
7
from conducting reviews for medical necessity, clinical
8
appropriateness, safety, fraud, waste, or abuse and reporting
9
suspected fraud, waste, or abuse according to State and
10
federal requirements. Nothing in this Section limits the
11
authority of the Department of Healthcare and Family Services
12
or another State agency, or a Medicaid managed care
13
organization on the State agency's behalf, to (i) implement or
14
require programs, services, screenings, assessments, tools, or
15
reviews to comply with applicable federal law, federal
16
regulation, federal grant requirements, any State or federal
17
consent decrees or court orders, or any applicable case law,
18
such as Olmstead v. L.C., 527 U.S. 581 (1999), or (ii)
19
administer or require programs, services, screenings,
20
assessments, tools, or reviews established under State or
21
federal laws, rules, or regulations in compliance with State
22
or federal laws, rules, or regulations, including, but not
23
limited to, the Children's Mental Health Act and the Mental
24
Health and Developmental Disabilities Administrative Act.
25

(y) (Blank).
26

(z) Notwithstanding any other provision of this Code, a

SB3900
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1
health insurance issuer subject to regulation under this Code
2
shall comply with standardized reimbursement rates and payment
3
methodologies established by the Illinois Health Care Cost and
4
Payment Board under the Illinois All-Payer Health Care Payment
5
and Global Budget Act. Any contract provision inconsistent
6
with such standardized rates is void as against public policy.

7
(Source: P.A. 103-426, eff. 8-4-23; 103-650, eff. 1-1-25;
8
103-1040, eff. 8-9-24; 104-28, eff. 1-1-26; 104-417, eff.
9
8-15-25
.)

10

Section 87.
The Health Maintenance Organization Act is
11
amended by changing Section 4-2 as follows:

12

(215 ILCS 125/4-2)

(from Ch. 111 1/2, par. 1408.2)
13

Sec. 4-2.
Medical assistance; coverage of child.
14

(a) In this Section, "Medicaid" means medical assistance
15
authorized under Section 1902 of the Social Security Act.
16

(b) A contract or evidence of coverage delivered, issued
17
for delivery, renewed, or amended by a Health Maintenance
18
Organization may not contain any provision which limits or
19
excludes payments of health care services to or on behalf of
20
the enrollee because the enrollee or any covered dependent is
21
eligible for or is receiving Medicaid benefits in this or any
22
other state.
23

(c) To the extent that payment for covered expenses has
24
been made under Article V, VI, or VII of the Illinois Public

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1
Aid Code for health care services provided to an individual,
2
if a third party has a legal liability to make payments for
3
those health care services, the State is considered to have
4
acquired the rights of the individual to payment.
5

(d) If a child is covered under a health care plan of a
6
Health Maintenance Organization in which the child's
7
noncustodial parent is an enrollee, the Health Maintenance
8
Organization shall:

9

(1) Provide necessary information to the child's
10

custodial parent to enable the child to obtain benefits
11

under that health care plan.

12

(2) Permit the child's custodial parent (or the
13

provider, with the custodial parent's approval) to submit
14

claims for payment for covered services without the
15

approval of the noncustodial parent.

16

(3) Make payments on claims submitted in accordance
17

with paragraph (2) directly to the custodial parent, the
18

provider of health care services, or the state Medicaid
19

agency.
20

(e) A Health Maintenance Organization may not deny
21
enrollment of a child under the health care plan in which the
22
child's parent is an enrollee on any of the following grounds:

23

(1) The child was born out of wedlock.

24

(2) The child is not claimed as a dependent on the
25

parent's federal income tax return.

26

(3) The child does not reside with the parent or in the

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1

service area covered by the health care plan.
2

(f) If a parent is required by a court or administrative
3
order to provide coverage for a child under a health care plan
4
in which the parent is enrolled, and that offers coverage for
5
eligible dependents, the Health Maintenance Organization, upon
6
receiving a copy of the order, shall:

7

(1) Upon application, permit the parent to enroll in
8

the health care plan a child who is otherwise eligible for
9

that coverage, without regard to any enrollment season
10

restrictions that might otherwise be applicable as to the
11

time period within which a person may enroll in the plan.

12

(2) Enroll the child in the health care plan upon
13

application of the child's other parent, the state agency
14

administering the Medicaid program, or the state agency
15

administering a program for enforcing child support and
16

establishing paternity under 42 U.S.C. 651 through 669 (or
17

another child support enforcement program), if the parent
18

is enrolled in the health care plan but fails to apply for
19

enrollment of the child.
20

(g) A Health Maintenance Organization may not impose, on a
21
state agency that has been assigned the rights of an enrollee
22
in a health care plan who receives Medicaid benefits,
23
requirements that are different from requirements applicable
24
to an assignee of any other enrollee in that health care plan.
25

(h) Nothing in subsections (e) and (f) prevents a Health
26
Maintenance Organization from denying any such application if

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1
the child is not eligible for coverage according to the Health
2
Maintenance Organization's medical underwriting standards.
3

(i) The Health Maintenance Organization may not disenroll
4
(or otherwise eliminate coverage of) the child from the health
5
care plan unless the Health Maintenance Organization is
6
provided satisfactory written evidence of either of the
7
following:

8

(1) The court or administrative order is no longer in
9

effect.

10

(2) The child is or will be enrolled in a comparable
11

health care plan obtained by the parent under such order
12

and that enrollment is currently in effect or will take
13

effect not later than the date the prior coverage is
14

terminated.
15

(j) A Health Maintenance Organization shall reimburse
16
hospitals in accordance with standardized reimbursement rates
17
and methodologies established by the Illinois Health Care Cost
18
and Payment Board pursuant to the Illinois All-Payer Health
19
Care Payment and Global Budget Act.

20
(Source: P.A. 89-183, eff. 1-1-96.)

21

Section 89.
The Illinois Public Aid Code is amended by
22
changing Section 5-5 as follows:

23

(305 ILCS 5/5-5)
24

Sec. 5-5.
Medical services.
The Illinois Department, by

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1
rule, shall determine the quantity and quality of and the rate
2
of reimbursement for the medical assistance for which payment
3
will be authorized, and the medical services to be provided,
4
which may include all or part of the following: (1) inpatient
5
hospital services; (2) outpatient hospital services; (3) other
6
laboratory and X-ray services; (4) skilled nursing home
7
services; (5) physicians' services whether furnished in the
8
office, the patient's home, a hospital, a skilled nursing
9
home, or elsewhere; (6) medical care, or any other type of
10
remedial care furnished by licensed practitioners; (7) home
11
health care services; (8) private duty nursing service; (9)
12
clinic services; (10) dental services, including prevention
13
and treatment of periodontal disease and dental caries disease
14
for pregnant individuals, provided by an individual licensed
15
to practice dentistry or dental surgery; for purposes of this
16
item (10), "dental services" means diagnostic, preventive, or
17
corrective procedures provided by or under the supervision of
18
a dentist in the practice of his or her profession; (11)
19
physical therapy and related services; (12) prescribed drugs,
20
dentures, and prosthetic devices; and eyeglasses prescribed by
21
a physician skilled in the diseases of the eye, or by an
22
optometrist, whichever the person may select; (13) other
23
diagnostic, screening, preventive, and rehabilitative
24
services, including to ensure that the individual's need for
25
intervention or treatment of mental disorders or substance use
26
disorders or co-occurring mental health and substance use

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1
disorders is determined using a uniform screening, assessment,
2
and evaluation process inclusive of criteria, for children and
3
adults; for purposes of this item (13), a uniform screening,
4
assessment, and evaluation process refers to a process that
5
includes an appropriate evaluation and, as warranted, a
6
referral; "uniform" does not mean the use of a singular
7
instrument, tool, or process that all must utilize; (14)
8
transportation and such other expenses as may be necessary;
9
(15) medical treatment of sexual assault survivors, as defined
10
in Section 1a of the Sexual Assault Survivors Emergency
11
Treatment Act, for injuries sustained as a result of the
12
sexual assault, including examinations and laboratory tests to
13
discover evidence which may be used in criminal proceedings
14
arising from the sexual assault; (16) the diagnosis and
15
treatment of sickle cell anemia; (16.5) services performed by
16
a chiropractic physician licensed under the Medical Practice
17
Act of 1987 and acting within the scope of his or her license,
18
including, but not limited to, chiropractic manipulative
19
treatment; and (17) any other medical care, and any other type
20
of remedial care recognized under the laws of this State. The
21
term "any other type of remedial care" shall include nursing
22
care and nursing home service for persons who rely on
23
treatment by spiritual means alone through prayer for healing.
24

Notwithstanding any other provision of this Section, a
25
comprehensive tobacco use cessation program that includes
26
purchasing prescription drugs or prescription medical devices

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1
approved by the Food and Drug Administration shall be covered
2
under the medical assistance program under this Article for
3
persons who are otherwise eligible for assistance under this
4
Article.
5

Notwithstanding any other provision of this Code,
6
reproductive health care that is otherwise legal in Illinois
7
shall be covered under the medical assistance program for
8
persons who are otherwise eligible for medical assistance
9
under this Article.
10

Notwithstanding any other provision of this Section, all
11
tobacco cessation medications approved by the United States
12
Food and Drug Administration and all individual and group
13
tobacco cessation counseling services and telephone-based
14
counseling services and tobacco cessation medications provided
15
through the Illinois Tobacco Quitline shall be covered under
16
the medical assistance program for persons who are otherwise
17
eligible for assistance under this Article. The Department
18
shall comply with all federal requirements necessary to obtain
19
federal financial participation, as specified in 42 CFR
20
433.15(b)(7), for telephone-based counseling services provided
21
through the Illinois Tobacco Quitline, including, but not
22
limited to: (i) entering into a memorandum of understanding or
23
interagency agreement with the Department of Public Health, as
24
administrator of the Illinois Tobacco Quitline; and (ii)
25
developing a cost allocation plan for Medicaid-allowable
26
Illinois Tobacco Quitline services in accordance with 45 CFR

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1
95.507. The Department shall submit the memorandum of
2
understanding or interagency agreement, the cost allocation
3
plan, and all other necessary documentation to the Centers for
4
Medicare and Medicaid Services for review and approval.
5
Coverage under this paragraph shall be contingent upon federal
6
approval.
7

Notwithstanding any other provision of this Code, the
8
Illinois Department may not require, as a condition of payment
9
for any laboratory test authorized under this Article, that a
10
physician's handwritten signature appear on the laboratory
11
test order form. The Illinois Department may, however, impose
12
other appropriate requirements regarding laboratory test order
13
documentation.
14

Upon receipt of federal approval of an amendment to the
15
Illinois Title XIX State Plan for this purpose, the Department
16
shall authorize the Chicago Public Schools (CPS) to procure a
17
vendor or vendors to manufacture eyeglasses for individuals
18
enrolled in a school within the CPS system. CPS shall ensure
19
that its vendor or vendors are enrolled as providers in the
20
medical assistance program and in any capitated Medicaid
21
managed care entity (MCE) serving individuals enrolled in a
22
school within the CPS system. Under any contract procured
23
under this provision, the vendor or vendors must serve only
24
individuals enrolled in a school within the CPS system. Claims
25
for services provided by CPS's vendor or vendors to recipients
26
of benefits in the medical assistance program under this Code,

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1
the Children's Health Insurance Program, or the Covering ALL
2
KIDS Health Insurance Program shall be submitted to the
3
Department or the MCE in which the individual is enrolled for
4
payment and shall be reimbursed at the Department's or the
5
MCE's established rates or rate methodologies for eyeglasses.
6

On and after July 1, 2012, the Department of Healthcare
7
and Family Services may provide the following services to
8
persons eligible for assistance under this Article who are
9
participating in education, training or employment programs
10
operated by the Department of Human Services as successor to
11
the Department of Public Aid:
12

(1) dental services provided by or under the
13

supervision of a dentist; and
14

(2) eyeglasses prescribed by a physician skilled in
15

the diseases of the eye, or by an optometrist, whichever
16

the person may select.
17

On and after July 1, 2018, the Department of Healthcare
18
and Family Services shall provide dental services to any adult
19
who is otherwise eligible for assistance under the medical
20
assistance program. As used in this paragraph, "dental
21
services" means diagnostic, preventative, restorative, or
22
corrective procedures, including procedures and services for
23
the prevention and treatment of periodontal disease and dental
24
caries disease, provided by an individual who is licensed to
25
practice dentistry or dental surgery or who is under the
26
supervision of a dentist in the practice of his or her

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1
profession.
2

On and after July 1, 2018, targeted dental services, as
3
set forth in Exhibit D of the Consent Decree entered by the
4
United States District Court for the Northern District of
5
Illinois, Eastern Division, in the matter of Memisovski v.
6
Maram, Case No. 92 C 1982, that are provided to adults under
7
the medical assistance program shall be established at no less
8
than the rates set forth in the "New Rate" column in Exhibit D
9
of the Consent Decree for targeted dental services that are
10
provided to persons under the age of 18 under the medical
11
assistance program.
12

Subject to federal approval, on and after January 1, 2025,
13
the rates paid for sedation evaluation and the provision of
14
deep sedation and intravenous sedation for the purpose of
15
dental services shall be increased by 33% above the rates in
16
effect on December 31, 2024. The rates paid for nitrous oxide
17
sedation shall not be impacted by this paragraph and shall
18
remain the same as the rates in effect on December 31, 2024.
19

Notwithstanding any other provision of this Code and
20
subject to federal approval, the Department may adopt rules to
21
allow a dentist who is volunteering his or her service at no
22
cost to render dental services through an enrolled
23
not-for-profit health clinic without the dentist personally
24
enrolling as a participating provider in the medical
25
assistance program. A not-for-profit health clinic shall
26
include a public health clinic or Federally Qualified Health

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1
Center or other enrolled provider, as determined by the
2
Department, through which dental services covered under this
3
Section are performed. The Department shall establish a
4
process for payment of claims for reimbursement for covered
5
dental services rendered under this provision.
6

Subject to appropriation and to federal approval, the
7
Department shall file administrative rules updating the
8
Handicapping Labio-Lingual Deviation orthodontic scoring tool
9
by January 1, 2025, or as soon as practicable.
10

On and after January 1, 2022, the Department of Healthcare
11
and Family Services shall administer and regulate a
12
school-based dental program that allows for the out-of-office
13
delivery of preventative dental services in a school setting
14
to children under 19 years of age. The Department shall
15
establish, by rule, guidelines for participation by providers
16
and set requirements for follow-up referral care based on the
17
requirements established in the Dental Office Reference Manual
18
published by the Department that establishes the requirements
19
for dentists participating in the All Kids Dental School
20
Program. Every effort shall be made by the Department when
21
developing the program requirements to consider the different
22
geographic differences of both urban and rural areas of the
23
State for initial treatment and necessary follow-up care. No
24
provider shall be charged a fee by any unit of local government
25
to participate in the school-based dental program administered
26
by the Department. Nothing in this paragraph shall be

SB3900
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1
construed to limit or preempt a home rule unit's or school
2
district's authority to establish, change, or administer a
3
school-based dental program in addition to, or independent of,
4
the school-based dental program administered by the
5
Department.
6

The Illinois Department, by rule, may distinguish and
7
classify the medical services to be provided only in
8
accordance with the classes of persons designated in Section
9
5-2.
10

The Department of Healthcare and Family Services must
11
provide coverage and reimbursement for amino acid-based
12
elemental formulas, regardless of delivery method, for the
13
diagnosis and treatment of (i) eosinophilic disorders and (ii)
14
short bowel syndrome when the prescribing physician has issued
15
a written order stating that the amino acid-based elemental
16
formula is medically necessary.
17

The Illinois Department shall authorize the provision of,
18
and shall authorize payment for, screening by low-dose
19
mammography for the presence of occult breast cancer for
20
individuals 35 years of age or older who are eligible for
21
medical assistance under this Article, as follows:
22

(A) A baseline mammogram for individuals 35 to 39
23

years of age.
24

(B) An annual mammogram for individuals 40 years of
25

age or older.
26

(C) A mammogram at the age and intervals considered

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1

medically necessary by the individual's health care
2

provider for individuals under 40 years of age and having
3

a family history of breast cancer, prior personal history
4

of breast cancer, positive genetic testing, or other risk
5

factors.
6

(D) A comprehensive ultrasound screening and MRI of an
7

entire breast or breasts if a mammogram demonstrates
8

heterogeneous or dense breast tissue or when medically
9

necessary as determined by a physician licensed to
10

practice medicine in all of its branches.
11

(E) A screening MRI when medically necessary, as
12

determined by a physician licensed to practice medicine in
13

all of its branches.
14

(F) A diagnostic mammogram when medically necessary,
15

as determined by a physician licensed to practice medicine
16

in all its branches, advanced practice registered nurse,
17

or physician assistant.
18

(G) Molecular breast imaging (MBI) and MRI of an
19

entire breast or breasts if a mammogram demonstrates
20

heterogeneous or dense breast tissue or when medically
21

necessary as determined by a physician licensed to
22

practice medicine in all of its branches, advanced
23

practice registered nurse, or physician assistant.
24

The Department shall not impose a deductible, coinsurance,
25
copayment, or any other cost-sharing requirement on the
26
coverage provided under this paragraph; except that this

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1
sentence does not apply to coverage of diagnostic mammograms
2
to the extent such coverage would disqualify a high-deductible
3
health plan from eligibility for a health savings account
4
pursuant to Section 223 of the Internal Revenue Code (26
5
U.S.C. 223).
6

All screenings shall include a physical breast exam,
7
instruction on self-examination and information regarding the
8
frequency of self-examination and its value as a preventative
9
tool.
10

For purposes of this Section:
11

"Diagnostic mammogram" means a mammogram obtained using
12
diagnostic mammography.
13

"Diagnostic mammography" means a method of screening that
14
is designed to evaluate an abnormality in a breast, including
15
an abnormality seen or suspected on a screening mammogram or a
16
subjective or objective abnormality otherwise detected in the
17
breast.
18

"Low-dose mammography" means the x-ray examination of the
19
breast using equipment dedicated specifically for mammography,
20
including the x-ray tube, filter, compression device, and
21
image receptor, with an average radiation exposure delivery of
22
less than one rad per breast for 2 views of an average size
23
breast. The term also includes digital mammography and
24
includes breast tomosynthesis.
25

"Breast tomosynthesis" means a radiologic procedure that
26
involves the acquisition of projection images over the

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stationary breast to produce cross-sectional digital
2
three-dimensional images of the breast.
3

If, at any time, the Secretary of the United States
4
Department of Health and Human Services, or its successor
5
agency, promulgates rules or regulations to be published in
6
the Federal Register or publishes a comment in the Federal
7
Register or issues an opinion, guidance, or other action that
8
would require the State, pursuant to any provision of the
9
Patient Protection and Affordable Care Act (Public Law
10
111-148), including, but not limited to, 42 U.S.C.
11
18031(d)(3)(B) or any successor provision, to defray the cost
12
of any coverage for breast tomosynthesis outlined in this
13
paragraph, then the requirement that an insurer cover breast
14
tomosynthesis is inoperative other than any such coverage
15
authorized under Section 1902 of the Social Security Act, 42
16
U.S.C. 1396a, and the State shall not assume any obligation
17
for the cost of coverage for breast tomosynthesis set forth in
18
this paragraph.
19

On and after January 1, 2016, the Department shall ensure
20
that all networks of care for adult clients of the Department
21
include access to at least one breast imaging Center of
22
Imaging Excellence as certified by the American College of
23
Radiology.
24

On and after January 1, 2012, providers participating in a
25
quality improvement program approved by the Department shall
26
be reimbursed for screening and diagnostic mammography at the

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same rate as the Medicare program's rates, including the
2
increased reimbursement for digital mammography and, after
3
January 1, 2023 (the effective date of Public Act 102-1018),
4
breast tomosynthesis.
5

The Department shall convene an expert panel including
6
representatives of hospitals, free-standing mammography
7
facilities, and doctors, including radiologists, to establish
8
quality standards for mammography.
9

On and after January 1, 2017, providers participating in a
10
breast cancer treatment quality improvement program approved
11
by the Department shall be reimbursed for breast cancer
12
treatment at a rate that is no lower than 95% of the Medicare
13
program's rates for the data elements included in the breast
14
cancer treatment quality program.
15

The Department shall convene an expert panel, including
16
representatives of hospitals, free-standing breast cancer
17
treatment centers, breast cancer quality organizations, and
18
doctors, including radiologists that are trained in all forms
19
of FDA-approved breast imaging technologies, breast surgeons,
20
reconstructive breast surgeons, oncologists, and primary care
21
providers to establish quality standards for breast cancer
22
treatment.
23

Subject to federal approval, the Department shall
24
establish a rate methodology for mammography at federally
25
qualified health centers and other encounter-rate clinics.
26
These clinics or centers may also collaborate with other

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hospital-based mammography facilities. By January 1, 2016, the
2
Department shall report to the General Assembly on the status
3
of the provision set forth in this paragraph.
4

The Department shall establish a methodology to remind
5
individuals who are age-appropriate for screening mammography,
6
but who have not received a mammogram within the previous 18
7
months, of the importance and benefit of screening
8
mammography. The Department shall work with experts in breast
9
cancer outreach and patient navigation to optimize these
10
reminders and shall establish a methodology for evaluating
11
their effectiveness and modifying the methodology based on the
12
evaluation.
13

The Department shall establish a performance goal for
14
primary care providers with respect to their female patients
15
over age 40 receiving an annual mammogram. This performance
16
goal shall be used to provide additional reimbursement in the
17
form of a quality performance bonus to primary care providers
18
who meet that goal.
19

The Department shall devise a means of case-managing or
20
patient navigation for beneficiaries diagnosed with breast
21
cancer. This program shall initially operate as a pilot
22
program in areas of the State with the highest incidence of
23
mortality related to breast cancer. At least one pilot program
24
site shall be in the metropolitan Chicago area and at least one
25
site shall be outside the metropolitan Chicago area. On or
26
after July 1, 2016, the pilot program shall be expanded to

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include one site in western Illinois, one site in southern
2
Illinois, one site in central Illinois, and 4 sites within
3
metropolitan Chicago. An evaluation of the pilot program shall
4
be carried out measuring health outcomes and cost of care for
5
those served by the pilot program compared to similarly
6
situated patients who are not served by the pilot program.
7

The Department shall require all networks of care to
8
develop a means either internally or by contract with experts
9
in navigation and community outreach to navigate cancer
10
patients to comprehensive care in a timely fashion. The
11
Department shall require all networks of care to include
12
access for patients diagnosed with cancer to at least one
13
academic commission on cancer-accredited cancer program as an
14
in-network covered benefit.
15

The Department shall provide coverage and reimbursement
16
for a human papillomavirus (HPV) vaccine that is approved for
17
marketing by the federal Food and Drug Administration for all
18
persons between the ages of 9 and 45. Subject to federal
19
approval, the Department shall provide coverage and
20
reimbursement for a human papillomavirus (HPV) vaccine for
21
persons of the age of 46 and above who have been diagnosed with
22
cervical dysplasia with a high risk of recurrence or
23
progression. The Department shall disallow any
24
preauthorization requirements for the administration of the
25
human papillomavirus (HPV) vaccine.
26

On or after July 1, 2022, individuals who are otherwise

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eligible for medical assistance under this Article shall
2
receive coverage for perinatal depression screenings for the
3
12-month period beginning on the last day of their pregnancy.
4
Medical assistance coverage under this paragraph shall be
5
conditioned on the use of a screening instrument approved by
6
the Department.
7

Any medical or health care provider shall immediately
8
recommend, to any pregnant individual who is being provided
9
prenatal services and is suspected of having a substance use
10
disorder as defined in the Substance Use Disorder Act,
11
referral to a local substance use disorder treatment program
12
licensed by the Department of Human Services or to a licensed
13
hospital which provides substance abuse treatment services.
14
The Department of Healthcare and Family Services shall assure
15
coverage for the cost of treatment of the drug abuse or
16
addiction for pregnant recipients in accordance with the
17
Illinois Medicaid Program in conjunction with the Department
18
of Human Services.
19

All medical providers providing medical assistance to
20
pregnant individuals under this Code shall receive information
21
from the Department on the availability of services under any
22
program providing case management services for addicted
23
individuals, including information on appropriate referrals
24
for other social services that may be needed by addicted
25
individuals in addition to treatment for addiction.
26

The Illinois Department, in cooperation with the

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Departments of Human Services (as successor to the Department
2
of Alcoholism and Substance Abuse) and Public Health, through
3
a public awareness campaign, may provide information
4
concerning treatment for alcoholism and drug abuse and
5
addiction, prenatal health care, and other pertinent programs
6
directed at reducing the number of drug-affected infants born
7
to recipients of medical assistance.
8

Neither the Department of Healthcare and Family Services
9
nor the Department of Human Services shall sanction the
10
recipient solely on the basis of the recipient's substance
11
abuse.
12

The Illinois Department shall establish such regulations
13
governing the dispensing of health services under this Article
14
as it shall deem appropriate. The Department should seek the
15
advice of formal professional advisory committees appointed by
16
the Director of the Illinois Department for the purpose of
17
providing regular advice on policy and administrative matters,
18
information dissemination and educational activities for
19
medical and health care providers, and consistency in
20
procedures to the Illinois Department.
21

The Illinois Department may develop and contract with
22
Partnerships of medical providers to arrange medical services
23
for persons eligible under Section 5-2 of this Code.
24
Implementation of this Section may be by demonstration
25
projects in certain geographic areas. The Partnership shall be
26
represented by a sponsor organization. The Department, by

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rule, shall develop qualifications for sponsors of
2
Partnerships. Nothing in this Section shall be construed to
3
require that the sponsor organization be a medical
4
organization.
5

The sponsor must negotiate formal written contracts with
6
medical providers for physician services, inpatient and
7
outpatient hospital care, home health services, treatment for
8
alcoholism and substance abuse, and other services determined
9
necessary by the Illinois Department by rule for delivery by
10
Partnerships. Physician services must include prenatal and
11
obstetrical care. The Illinois Department shall reimburse
12
medical services delivered by Partnership providers to clients
13
in target areas according to provisions of this Article and
14
the Illinois Health Finance Reform Act, except that:
15

(1) Physicians participating in a Partnership and
16

providing certain services, which shall be determined by
17

the Illinois Department, to persons in areas covered by
18

the Partnership may receive an additional surcharge for
19

such services.
20

(2) The Department may elect to consider and negotiate
21

financial incentives to encourage the development of
22

Partnerships and the efficient delivery of medical care.
23

(3) Persons receiving medical services through
24

Partnerships may receive medical and case management
25

services above the level usually offered through the
26

medical assistance program.

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Medical providers shall be required to meet certain
2
qualifications to participate in Partnerships to ensure the
3
delivery of high quality medical services. These
4
qualifications shall be determined by rule of the Illinois
5
Department and may be higher than qualifications for
6
participation in the medical assistance program. Partnership
7
sponsors may prescribe reasonable additional qualifications
8
for participation by medical providers, only with the prior
9
written approval of the Illinois Department.
10

Nothing in this Section shall limit the free choice of
11
practitioners, hospitals, and other providers of medical
12
services by clients. In order to ensure patient freedom of
13
choice, the Illinois Department shall immediately promulgate
14
all rules and take all other necessary actions so that
15
provided services may be accessed from therapeutically
16
certified optometrists to the full extent of the Illinois
17
Optometric Practice Act of 1987 without discriminating between
18
service providers.
19

The Department shall apply for a waiver from the United
20
States Health Care Financing Administration to allow for the
21
implementation of Partnerships under this Section.
22

The Illinois Department shall require health care
23
providers to maintain records that document the medical care
24
and services provided to recipients of Medical Assistance
25
under this Article. Such records must be retained for a period
26
of not less than 6 years from the date of service or as

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provided by applicable State law, whichever period is longer,
2
except that if an audit is initiated within the required
3
retention period then the records must be retained until the
4
audit is completed and every exception is resolved. The
5
Illinois Department shall require health care providers to
6
make available, when authorized by the patient, in writing,
7
the medical records in a timely fashion to other health care
8
providers who are treating or serving persons eligible for
9
Medical Assistance under this Article. All dispensers of
10
medical services shall be required to maintain and retain
11
business and professional records sufficient to fully and
12
accurately document the nature, scope, details and receipt of
13
the health care provided to persons eligible for medical
14
assistance under this Code, in accordance with regulations
15
promulgated by the Illinois Department. The rules and
16
regulations shall require that proof of the receipt of
17
prescription drugs, dentures, prosthetic devices and
18
eyeglasses by eligible persons under this Section accompany
19
each claim for reimbursement submitted by the dispenser of
20
such medical services. No such claims for reimbursement shall
21
be approved for payment by the Illinois Department without
22
such proof of receipt, unless the Illinois Department shall
23
have put into effect and shall be operating a system of
24
post-payment audit and review which shall, on a sampling
25
basis, be deemed adequate by the Illinois Department to assure
26
that such drugs, dentures, prosthetic devices and eyeglasses

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for which payment is being made are actually being received by
2
eligible recipients. Within 90 days after September 16, 1984
3
(the effective date of Public Act 83-1439), the Illinois
4
Department shall establish a current list of acquisition costs
5
for all prosthetic devices and any other items recognized as
6
medical equipment and supplies reimbursable under this Article
7
and shall update such list on a quarterly basis, except that
8
the acquisition costs of all prescription drugs shall be
9
updated no less frequently than every 30 days as required by
10
Section 5-5.12.
11

Notwithstanding any other law to the contrary, the
12
Illinois Department shall, within 365 days after July 22, 2013
13
(the effective date of Public Act 98-104), establish
14
procedures to permit skilled care facilities licensed under
15
the Nursing Home Care Act to submit monthly billing claims for
16
reimbursement purposes. Following development of these
17
procedures, the Department shall, by July 1, 2016, test the
18
viability of the new system and implement any necessary
19
operational or structural changes to its information
20
technology platforms in order to allow for the direct
21
acceptance and payment of nursing home claims.
22

Notwithstanding any other law to the contrary, the
23
Illinois Department shall, within 365 days after August 15,
24
2014 (the effective date of Public Act 98-963), establish
25
procedures to permit ID/DD facilities licensed under the ID/DD
26
Community Care Act and MC/DD facilities licensed under the

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MC/DD Act to submit monthly billing claims for reimbursement
2
purposes. Following development of these procedures, the
3
Department shall have an additional 365 days to test the
4
viability of the new system and to ensure that any necessary
5
operational or structural changes to its information
6
technology platforms are implemented.
7

The Illinois Department shall require all dispensers of
8
medical services, other than an individual practitioner or
9
group of practitioners, desiring to participate in the Medical
10
Assistance program established under this Article to disclose
11
all financial, beneficial, ownership, equity, surety or other
12
interests in any and all firms, corporations, partnerships,
13
associations, business enterprises, joint ventures, agencies,
14
institutions or other legal entities providing any form of
15
health care services in this State under this Article.
16

The Illinois Department may require that all dispensers of
17
medical services desiring to participate in the medical
18
assistance program established under this Article disclose,
19
under such terms and conditions as the Illinois Department may
20
by rule establish, all inquiries from clients and attorneys
21
regarding medical bills paid by the Illinois Department, which
22
inquiries could indicate potential existence of claims or
23
liens for the Illinois Department.
24

Enrollment of a vendor shall be subject to a provisional
25
period and shall be conditional for one year. During the
26
period of conditional enrollment, the Department may terminate

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the vendor's eligibility to participate in, or may disenroll
2
the vendor from, the medical assistance program without cause.
3
Unless otherwise specified, such termination of eligibility or
4
disenrollment is not subject to the Department's hearing
5
process. However, a disenrolled vendor may reapply without
6
penalty.
7

The Department has the discretion to limit the conditional
8
enrollment period for vendors based upon the category of risk
9
of the vendor.
10

Prior to enrollment and during the conditional enrollment
11
period in the medical assistance program, all vendors shall be
12
subject to enhanced oversight, screening, and review based on
13
the risk of fraud, waste, and abuse that is posed by the
14
category of risk of the vendor. The Illinois Department shall
15
establish the procedures for oversight, screening, and review,
16
which may include, but need not be limited to: criminal and
17
financial background checks; fingerprinting; license,
18
certification, and authorization verifications; unscheduled or
19
unannounced site visits; database checks; prepayment audit
20
reviews; audits; payment caps; payment suspensions; and other
21
screening as required by federal or State law.
22

The Department shall define or specify the following: (i)
23
by provider notice, the "category of risk of the vendor" for
24
each type of vendor, which shall take into account the level of
25
screening applicable to a particular category of vendor under
26
federal law and regulations; (ii) by rule or provider notice,

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the maximum length of the conditional enrollment period for
2
each category of risk of the vendor; and (iii) by rule, the
3
hearing rights, if any, afforded to a vendor in each category
4
of risk of the vendor that is terminated or disenrolled during
5
the conditional enrollment period.
6

To be eligible for payment consideration, a vendor's
7
payment claim or bill, either as an initial claim or as a
8
resubmitted claim following prior rejection, must be received
9
by the Illinois Department, or its fiscal intermediary, no
10
later than 180 days after the latest date on the claim on which
11
medical goods or services were provided, with the following
12
exceptions:
13

(1) In the case of a provider whose enrollment is in
14

process by the Illinois Department, the 180-day period
15

shall not begin until the date on the written notice from
16

the Illinois Department that the provider enrollment is
17

complete.
18

(2) In the case of errors attributable to the Illinois
19

Department or any of its claims processing intermediaries
20

which result in an inability to receive, process, or
21

adjudicate a claim, the 180-day period shall not begin
22

until the provider has been notified of the error.
23

(3) In the case of a provider for whom the Illinois
24

Department initiates the monthly billing process.
25

(4) In the case of a provider operated by a unit of
26

local government with a population exceeding 3,000,000

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when local government funds finance federal participation
2

for claims payments.
3

For claims for services rendered during a period for which
4
a recipient received retroactive eligibility, claims must be
5
filed within 180 days after the Department determines the
6
applicant is eligible. For claims for which the Illinois
7
Department is not the primary payer, claims must be submitted
8
to the Illinois Department within 180 days after the final
9
adjudication by the primary payer.
10

In the case of long term care facilities, within 120
11
calendar days of receipt by the facility of required
12
prescreening information, new admissions with associated
13
admission documents shall be submitted through the Medical
14
Electronic Data Interchange (MEDI) or the Recipient
15
Eligibility Verification (REV) System or shall be submitted
16
directly to the Department of Human Services using required
17
admission forms. Effective September 1, 2014, admission
18
documents, including all prescreening information, must be
19
submitted through MEDI or REV. Confirmation numbers assigned
20
to an accepted transaction shall be retained by a facility to
21
verify timely submittal. Once an admission transaction has
22
been completed, all resubmitted claims following prior
23
rejection are subject to receipt no later than 180 days after
24
the admission transaction has been completed.
25

Claims that are not submitted and received in compliance
26
with the foregoing requirements shall not be eligible for

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payment under the medical assistance program, and the State
2
shall have no liability for payment of those claims.
3

To the extent consistent with applicable information and
4
privacy, security, and disclosure laws, State and federal
5
agencies and departments shall provide the Illinois Department
6
access to confidential and other information and data
7
necessary to perform eligibility and payment verifications and
8
other Illinois Department functions. This includes, but is not
9
limited to: information pertaining to licensure;
10
certification; earnings; immigration status; citizenship; wage
11
reporting; unearned and earned income; pension income;
12
employment; supplemental security income; social security
13
numbers; National Provider Identifier (NPI) numbers; the
14
National Practitioner Data Bank (NPDB); program and agency
15
exclusions; taxpayer identification numbers; tax delinquency;
16
corporate information; and death records.
17

The Illinois Department shall enter into agreements with
18
State agencies and departments, and is authorized to enter
19
into agreements with federal agencies and departments, under
20
which such agencies and departments shall share data necessary
21
for medical assistance program integrity functions and
22
oversight. The Illinois Department shall develop, in
23
cooperation with other State departments and agencies, and in
24
compliance with applicable federal laws and regulations,
25
appropriate and effective methods to share such data. At a
26
minimum, and to the extent necessary to provide data sharing,

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the Illinois Department shall enter into agreements with State
2
agencies and departments, and is authorized to enter into
3
agreements with federal agencies and departments, including,
4
but not limited to: the Secretary of State; the Department of
5
Revenue; the Department of Public Health; the Department of
6
Human Services; and the Department of Financial and
7
Professional Regulation.
8

Beginning in fiscal year 2013, the Illinois Department
9
shall set forth a request for information to identify the
10
benefits of a pre-payment, post-adjudication, and post-edit
11
claims system with the goals of streamlining claims processing
12
and provider reimbursement, reducing the number of pending or
13
rejected claims, and helping to ensure a more transparent
14
adjudication process through the utilization of: (i) provider
15
data verification and provider screening technology; and (ii)
16
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
17
post-adjudicated predictive modeling with an integrated case
18
management system with link analysis. Such a request for
19
information shall not be considered as a request for proposal
20
or as an obligation on the part of the Illinois Department to
21
take any action or acquire any products or services.
22

The Illinois Department shall establish policies,
23
procedures, standards and criteria by rule for the
24
acquisition, repair and replacement of orthotic and prosthetic
25
devices and durable medical equipment. Such rules shall
26
provide, but not be limited to, the following services: (1)

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immediate repair or replacement of such devices by recipients;
2
and (2) rental, lease, purchase or lease-purchase of durable
3
medical equipment in a cost-effective manner, taking into
4
consideration the recipient's medical prognosis, the extent of
5
the recipient's needs, and the requirements and costs for
6
maintaining such equipment. Subject to prior approval, such
7
rules shall enable a recipient to temporarily acquire and use
8
alternative or substitute devices or equipment pending repairs
9
or replacements of any device or equipment previously
10
authorized for such recipient by the Department.
11
Notwithstanding any provision of Section 5-5f to the contrary,
12
the Department may, by rule, exempt certain replacement
13
wheelchair parts from prior approval and, for wheelchairs,
14
wheelchair parts, wheelchair accessories, and related seating
15
and positioning items, determine the wholesale price by
16
methods other than actual acquisition costs.
17

The Department shall require, by rule, all providers of
18
durable medical equipment to be accredited by an accreditation
19
organization approved by the federal Centers for Medicare and
20
Medicaid Services and recognized by the Department in order to
21
bill the Department for providing durable medical equipment to
22
recipients. No later than 15 months after the effective date
23
of the rule adopted pursuant to this paragraph, all providers
24
must meet the accreditation requirement.
25

In order to promote environmental responsibility, meet the
26
needs of recipients and enrollees, and achieve significant

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cost savings, the Department, or a managed care organization
2
under contract with the Department, may provide recipients or
3
managed care enrollees who have a prescription or Certificate
4
of Medical Necessity access to refurbished durable medical
5
equipment under this Section (excluding prosthetic and
6
orthotic devices as defined in the Orthotics, Prosthetics, and
7
Pedorthics Practice Act and complex rehabilitation technology
8
products and associated services) through the State's
9
assistive technology program's reutilization program, using
10
staff with the Assistive Technology Professional (ATP)
11
Certification if the refurbished durable medical equipment:
12
(i) is available; (ii) is less expensive, including shipping
13
costs, than new durable medical equipment of the same type;
14
(iii) is able to withstand at least 3 years of use; (iv) is
15
cleaned, disinfected, sterilized, and safe in accordance with
16
federal Food and Drug Administration regulations and guidance
17
governing the reprocessing of medical devices in health care
18
settings; and (v) equally meets the needs of the recipient or
19
enrollee. The reutilization program shall confirm that the
20
recipient or enrollee is not already in receipt of the same or
21
similar equipment from another service provider, and that the
22
refurbished durable medical equipment equally meets the needs
23
of the recipient or enrollee. Nothing in this paragraph shall
24
be construed to limit recipient or enrollee choice to obtain
25
new durable medical equipment or place any additional prior
26
authorization conditions on enrollees of managed care

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organizations.
2

The Department shall execute, relative to the nursing home
3
prescreening project, written inter-agency agreements with the
4
Department of Human Services and the Department on Aging, to
5
effect the following: (i) intake procedures and common
6
eligibility criteria for those persons who are receiving
7
non-institutional services; and (ii) the establishment and
8
development of non-institutional services in areas of the
9
State where they are not currently available or are
10
undeveloped; and (iii) notwithstanding any other provision of
11
law, subject to federal approval, on and after July 1, 2012, an
12
increase in the determination of need (DON) scores from 29 to
13
37 for applicants for institutional and home and
14
community-based long term care; if and only if federal
15
approval is not granted, the Department may, in conjunction
16
with other affected agencies, implement utilization controls
17
or changes in benefit packages to effectuate a similar savings
18
amount for this population; and (iv) no later than July 1,
19
2013, minimum level of care eligibility criteria for
20
institutional and home and community-based long term care; and
21
(v) no later than October 1, 2013, establish procedures to
22
permit long term care providers access to eligibility scores
23
for individuals with an admission date who are seeking or
24
receiving services from the long term care provider. In order
25
to select the minimum level of care eligibility criteria, the
26
Governor shall establish a workgroup that includes affected

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agency representatives and stakeholders representing the
2
institutional and home and community-based long term care
3
interests. This Section shall not restrict the Department from
4
implementing lower level of care eligibility criteria for
5
community-based services in circumstances where federal
6
approval has been granted.
7

The Illinois Department shall develop and operate, in
8
cooperation with other State Departments and agencies and in
9
compliance with applicable federal laws and regulations,
10
appropriate and effective systems of health care evaluation
11
and programs for monitoring of utilization of health care
12
services and facilities, as it affects persons eligible for
13
medical assistance under this Code.
14

The Illinois Department shall report annually to the
15
General Assembly, no later than the second Friday in April of
16
1979 and each year thereafter, in regard to:
17

(a) actual statistics and trends in utilization of
18

medical services by public aid recipients;
19

(b) actual statistics and trends in the provision of
20

the various medical services by medical vendors;
21

(c) current rate structures and proposed changes in
22

those rate structures for the various medical vendors; and
23

(d) efforts at utilization review and control by the
24

Illinois Department.
25

The period covered by each report shall be the 3 years
26
ending on the June 30 prior to the report. The report shall

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include suggested legislation for consideration by the General
2
Assembly. The requirement for reporting to the General
3
Assembly shall be satisfied by filing copies of the report as
4
required by Section 3.1 of the General Assembly Organization
5
Act, and filing such additional copies with the State
6
Government Report Distribution Center for the General Assembly
7
as is required under paragraph (t) of Section 7 of the State
8
Library Act.
9

Rulemaking authority to implement Public Act 95-1045, if
10
any, is conditioned on the rules being adopted in accordance
11
with all provisions of the Illinois Administrative Procedure
12
Act and all rules and procedures of the Joint Committee on
13
Administrative Rules; any purported rule not so adopted, for
14
whatever reason, is unauthorized.
15

On and after July 1, 2012, the Department shall reduce any
16
rate of reimbursement for services or other payments or alter
17
any methodologies authorized by this Code to reduce any rate
18
of reimbursement for services or other payments in accordance
19
with Section 5-5e.
20

Because kidney transplantation can be an appropriate,
21
cost-effective alternative to renal dialysis when medically
22
necessary and notwithstanding the provisions of Section 1-11
23
of this Code, beginning October 1, 2014, the Department shall
24
cover kidney transplantation for noncitizens with end-stage
25
renal disease who are not eligible for comprehensive medical
26
benefits, who meet the residency requirements of Section 5-3

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of this Code, and who would otherwise meet the financial
2
requirements of the appropriate class of eligible persons
3
under Section 5-2 of this Code. To qualify for coverage of
4
kidney transplantation, such person must be receiving
5
emergency renal dialysis services covered by the Department.
6
Providers under this Section shall be prior approved and
7
certified by the Department to perform kidney transplantation
8
and the services under this Section shall be limited to
9
services associated with kidney transplantation.
10

Notwithstanding any other provision of this Code to the
11
contrary, on or after July 1, 2015, all FDA-approved forms of
12
medication assisted treatment prescribed for the treatment of
13
alcohol dependence or treatment of opioid dependence shall be
14
covered under both fee-for-service and managed care medical
15
assistance programs for persons who are otherwise eligible for
16
medical assistance under this Article and shall not be subject
17
to any (1) utilization control, other than those established
18
under the American Society of Addiction Medicine patient
19
placement criteria, (2) prior authorization mandate, (3)
20
lifetime restriction limit mandate, or (4) limitations on
21
dosage.
22

On or after July 1, 2015, opioid antagonists prescribed
23
for the treatment of an opioid overdose, including the
24
medication product, administration devices, and any pharmacy
25
fees or hospital fees related to the dispensing, distribution,
26
and administration of the opioid antagonist, shall be covered

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1
under the medical assistance program for persons who are
2
otherwise eligible for medical assistance under this Article.
3
As used in this Section, "opioid antagonist" means a drug that
4
binds to opioid receptors and blocks or inhibits the effect of
5
opioids acting on those receptors, including, but not limited
6
to, naloxone hydrochloride or any other similarly acting drug
7
approved by the U.S. Food and Drug Administration. The
8
Department shall not impose a copayment on the coverage
9
provided for naloxone hydrochloride under the medical
10
assistance program.
11

Upon federal approval, the Department shall provide
12
coverage and reimbursement for all drugs that are approved for
13
marketing by the federal Food and Drug Administration and that
14
are recommended by the federal Public Health Service or the
15
United States Centers for Disease Control and Prevention for
16
pre-exposure prophylaxis and related pre-exposure prophylaxis
17
services, including, but not limited to, HIV and sexually
18
transmitted infection screening, treatment for sexually
19
transmitted infections, medical monitoring, assorted labs, and
20
counseling to reduce the likelihood of HIV infection among
21
individuals who are not infected with HIV but who are at high
22
risk of HIV infection.
23

A federally qualified health center, as defined in Section
24
1905(l)(2)(B) of the federal Social Security Act, shall be
25
reimbursed by the Department in accordance with the federally
26
qualified health center's encounter rate for services provided

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to medical assistance recipients that are performed by a
2
dental hygienist, as defined under the Illinois Dental
3
Practice Act, working under the general supervision of a
4
dentist and employed by a federally qualified health center.
5

Within 90 days after October 8, 2021 (the effective date
6
of Public Act 102-665), the Department shall seek federal
7
approval of a State Plan amendment to expand coverage for
8
family planning services that includes presumptive eligibility
9
to individuals whose income is at or below 208% of the federal
10
poverty level. Coverage under this Section shall be effective
11
beginning no later than December 1, 2022.
12

Subject to approval by the federal Centers for Medicare
13
and Medicaid Services of a Title XIX State Plan amendment
14
electing the Program of All-Inclusive Care for the Elderly
15
(PACE) as a State Medicaid option, as provided for by Subtitle
16
I (commencing with Section 4801) of Title IV of the Balanced
17
Budget Act of 1997 (Public Law 105-33) and Part 460
18
(commencing with Section 460.2) of Subchapter E of Title 42 of
19
the Code of Federal Regulations, PACE program services shall
20
become a covered benefit of the medical assistance program,
21
subject to criteria established in accordance with all
22
applicable laws.
23

Notwithstanding any other provision of this Code,
24
community-based pediatric palliative care from a trained
25
interdisciplinary team shall be covered under the medical
26
assistance program as provided in Section 15 of the Pediatric

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1
Palliative Care Act.
2

Notwithstanding any other provision of this Code, within
3
12 months after June 2, 2022 (the effective date of Public Act
4
102-1037) and subject to federal approval, acupuncture
5
services performed by an acupuncturist licensed under the
6
Acupuncture Practice Act who is acting within the scope of his
7
or her license shall be covered under the medical assistance
8
program. The Department shall apply for any federal waiver or
9
State Plan amendment, if required, to implement this
10
paragraph. The Department may adopt any rules, including
11
standards and criteria, necessary to implement this paragraph.
12

Notwithstanding any other provision of this Code, the
13
medical assistance program shall, subject to federal approval,
14
reimburse hospitals for costs associated with a newborn
15
screening test for the presence of metachromatic
16
leukodystrophy, as required under the Newborn Metabolic
17
Screening Act, at a rate not less than the fee charged by the
18
Department of Public Health. Notwithstanding any other
19
provision of this Code, the medical assistance program shall,
20
subject to appropriation and federal approval, also reimburse
21
hospitals for costs associated with all newborn screening
22
tests added on and after August 9, 2024 (the effective date of
23
Public Act 103-909) to the Newborn Metabolic Screening Act and
24
required to be performed under that Act at a rate not less than
25
the fee charged by the Department of Public Health. The
26
Department shall seek federal approval before the

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implementation of the newborn screening test fees by the
2
Department of Public Health.
3

Notwithstanding any other provision of this Code,
4
beginning on January 1, 2024, subject to federal approval,
5
cognitive assessment and care planning services provided to a
6
person who experiences signs or symptoms of cognitive
7
impairment, as defined by the Diagnostic and Statistical
8
Manual of Mental Disorders, Fifth Edition, shall be covered
9
under the medical assistance program for persons who are
10
otherwise eligible for medical assistance under this Article.
11

Notwithstanding any other provision of this Code,
12
medically necessary reconstructive services that are intended
13
to restore physical appearance shall be covered under the
14
medical assistance program for persons who are otherwise
15
eligible for medical assistance under this Article. As used in
16
this paragraph, "reconstructive services" means treatments
17
performed on structures of the body damaged by trauma to
18
restore physical appearance.
19

Subject to federal approval, for dates of services on and
20
after January 1, 2026, over-the-counter choline dietary
21
supplements for pregnant persons shall be covered under the
22
medical assistance program.
23

Subject to federal approval, the Department of Healthcare
24
and Family Services shall align Medicaid hospital
25
reimbursement with standardized rates and global hospital
26
budgets established by the Illinois Health Care Cost and

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1
Payment Board under the Illinois All-Payer Health Care Payment
2
and Global Budget Act.

3
(Source: P.A. 103-102, Article 15, Section 15-5, eff. 1-1-24;
4
103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff.
5
1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593,
6
Article 5, Section 5-5, eff. 6-7-24; 103-593, Article 90,
7
Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-808, eff.
8
1-1-26; 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; 104-9,
9
eff. 6-16-25; 104-417, eff. 8-15-25
.)

10

Section 97.
Severability.
The provisions of this Act are
11
severable under Section 1.31 of the Statute on Statutes.

12

Section 99.
Effective date.
This Act takes effect upon
13
becoming law.

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