(a) The Department of Healthcare and Family Services may provide reimbursement under this Article for all prenatal and perinatal health care services that are provided for the purpose of preventing low-birthweight infants, reducing the need for neonatal intensive care hospital services, and promoting perinatal and maternal health. These services may include comprehensive risk assessments for pregnant individuals, individuals with infants, and infants, lactation counseling, nutrition counseling, childbirth support, psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and other support services that have been proven to improve birth and maternal health outcomes. The Department shall maximize the use of preventive prenatal and perinatal health care services consistent with federal statutes, rules, and regulations. The Department of Public Aid (now Department of Healthcare and Family Services) shall develop a plan for prenatal and perinatal preventive health care and shall present the plan to the General Assembly by January 1, 2004. On or before January 1, 2006 and every 2 years thereafter, the Department shall report to the General Assembly concerning the effectiveness of prenatal and perinatal health care services reimbursed under this Section in preventing low-birthweight infants and reducing the need for neonatal intensive care hospital services. Each such report shall include an evaluation of how the ratio of expenditures for treating low-birthweight infants compared with the investment in promoting healthy births and infants in local community areas throughout Illinois relates to healthy infant development in those areas.
     On and after July 1, 2012, the Department shall reduce any 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.
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Terms Used In Illinois Compiled Statutes 305 ILCS 5/5-5.24

  • Contract: A legal written agreement that becomes binding when signed.
  • Fraud: Intentional deception resulting in injury to another.

     (b)(1) As used in this subsection:
     “Affiliated provider” means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization.
     “Non-affiliated provider” means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO.
     “Preventive prenatal and perinatal health care services” means services described in subsection (a) including the following non-emergent diagnostic and ancillary services:
         (i) Diagnostic labs and imaging, including level II
    
ultrasounds.
        (ii) RhoGAM injections.
         (iii) Injectable 17-alpha-hydroxyprogesterone
    
caproate (commonly called 17P).
        (iv) Intrapartum (labor and delivery) services.
         (v) Any other outpatient or inpatient service
    
relating to pregnancy or the 12 months following childbirth or fetal loss.
    (2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, including all policy adjusters, including, but not limited to, Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates, unless a different rate was agreed upon by the health plan and the non-affiliated provider.
     (3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and:
         (A) the non-affiliated provider is a perinatal
    
hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department; or
        (B) the health plan has terminated a contract with
    
the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. The Department may deem that a determination for cause has merit if:
            (i) an institutional provider has repeatedly
        
failed to conduct discharge planning; or
            (ii) the provider’s conduct adversely and
        
substantially impacts the health of Medicaid patients; or
            (iii) the provider’s conduct constitutes fraud,
        
waste, or abuse; or
            (iv) the provider’s conduct violates the code of
        
ethics governing his or her profession.
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