SB 3103 — MEDICAID-SICKLE CELL DISEASE

*LRB10418976KTG32421b* SB3103 104THEngrossed GENERALLRB104 ASSEMBLY18976 StateKTG of32421 Illinoisb andAN 2026ACT SB3103concerning Introducedpublic 1/29/2026,code. by Sen.

Mattie Hunter SYNOPSIS AS INTRODUCED:

ILCS 5/5-5 Code.

Provides medical assistance coverage for sickle cell disease (rather than sickle cell anemia).

LRB104 18976 KTG 32421 b A BILL FOR SB3103 LRB104 18976 KTG 32421 b AN ACT concerning public code.

for purposes of this item (10), "dental services" means diagnostic, preventive, or SB3103 Engrossed - 2 - LRB104 18976 KTG 32421 b corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession;

(16.5) services performed by a chiropractic physician licensed under the SB3103 Engrossed - 3 - LRB104 18976 KTG 32421 b Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment;

Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under SB3103 Engrossed - 4 - LRB104 18976 KTG 32421 b the medical assistance program for persons who are otherwise eligible for assistance under this Article.

Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department SB3103 Engrossed - 5 - LRB104 18976 KTG 32421 b shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system.

and (2) eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever SB3103 Engrossed - 6 - LRB104 18976 KTG 32421 b the person may select.

Subject to federal approval, on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in SB3103 Engrossed - 7 - LRB104 18976 KTG 32421 b effect on December 31, 2024.

The Department shall establish, by rule, guidelines for participation by providers SB3103 Engrossed - 8 - LRB104 18976 KTG 32421 b and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program.

The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental SB3103 Engrossed - 9 - LRB104 18976 KTG 32421 b formula is medically necessary.

(F) A diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine SB3103 Engrossed - 10 - LRB104 18976 KTG 32421 b in all its branches, advanced practice registered nurse, or physician assistant.

"Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a SB3103 Engrossed - 11 - LRB104 18976 KTG 32421 b subjective or objective abnormality otherwise detected in the breast.

18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 SB3103 Engrossed - 12 - LRB104 18976 KTG 32421 b U.S.C.

The Department shall convene an expert panel, including SB3103 Engrossed - 13 - LRB104 18976 KTG 32421 b representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including radiologists that are trained in all forms of FDA-approved breast imaging technologies, breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.

This performance SB3103 Engrossed - 14 - LRB104 18976 KTG 32421 b goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.

The Department shall provide coverage and reimbursement SB3103 Engrossed - 15 - LRB104 18976 KTG 32421 b for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45.

The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or SB3103 Engrossed - 16 - LRB104 18976 KTG 32421 b addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services.

The Department should seek the advice of formal professional advisory committees appointed by SB3103 Engrossed - 17 - LRB104 18976 KTG 32421 b the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department.

(1) Physicians participating in a Partnership and SB3103 Engrossed - 18 - LRB104 18976 KTG 32421 b providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.

In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically SB3103 Engrossed - 19 - LRB104 18976 KTG 32421 b certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers.

The rules and SB3103 Engrossed - 20 - LRB104 18976 KTG 32421 b regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services.

Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for SB3103 Engrossed - 21 - LRB104 18976 KTG 32421 b reimbursement purposes.

SB3103 Engrossed - 22 - LRB104 18976 KTG 32421 b The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department.

The Illinois Department shall establish the procedures for oversight, screening, and review, SB3103 Engrossed - 23 - LRB104 18976 KTG 32421 b which may include, but need not be limited to:

(1) In the case of a provider whose enrollment is in process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from SB3103 Engrossed - 24 - LRB104 18976 KTG 32421 b the Illinois Department that the provider enrollment is complete.

In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted SB3103 Engrossed - 25 - LRB104 18976 KTG 32421 b directly to the Department of Human Services using required admission forms.

SB3103 Engrossed - 26 - LRB104 18976 KTG 32421 b corporate information;

and (ii) SB3103 Engrossed - 27 - LRB104 18976 KTG 32421 b clinical code editing;

Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by SB3103 Engrossed - 28 - LRB104 18976 KTG 32421 b methods other than actual acquisition costs.

(iv) is cleaned, disinfected, sterilized, and safe in accordance with SB3103 Engrossed - 29 - LRB104 18976 KTG 32421 b federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings;

if and only if federal approval is not granted, the Department may, in conjunction SB3103 Engrossed - 30 - LRB104 18976 KTG 32421 b with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population;

The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of SB3103 Engrossed - 31 - LRB104 18976 KTG 32421 b 1979 and each year thereafter, in regard to:

On and after July 1, 2012, the Department shall reduce any SB3103 Engrossed - 32 - LRB104 18976 KTG 32421 b rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA-approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for SB3103 Engrossed - 33 - LRB104 18976 KTG 32421 b medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, (3) lifetime restriction limit mandate, or (4) limitations on dosage.

Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for SB3103 Engrossed - 34 - LRB104 18976 KTG 32421 b pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.

Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle SB3103 Engrossed - 35 - LRB104 18976 KTG 32421 b I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws.

Notwithstanding any other provision of this Code, the medical assistance program shall, subject to federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic SB3103 Engrossed - 36 - LRB104 18976 KTG 32421 b leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health.