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SB2437 Enrolled LRB104 10548 KTG 20624 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 ARTICLE 2.
5 Section 2-1. Short title. This Article may be cited as the
6 Certified Family Health Aide Program for Children and Adults
7 Act. References in this Article to "this Act" mean this
8 Article.
9 Section 2-5. Purpose. The purpose of this Act is to create
10 the certified family health aide designation.
11 Section 2-10. Definition. As used in this Act, "certified
12 family health aide" means a person who:
13 (1) is 18 years of age or older;
14 (2) has the following relationship with the family
15 member receiving or who is eligible to receive the
16 services enumerated in this Section:
17 (i) spouse;
18 (ii) sibling or stepsibling;
19 (iii) parent, stepparent, or adoptive parent;
20 (iv) grandparent;
21 (v) mother-in-law or father-in-law;
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1 (vi) brother-in-law or sister-in-law;
2 (vii) legal guardian; or
3 (viii) caregiver designated by the legally
4 responsible caregiver as documented in the Medical
5 Plan of Care;
6 (3) is a legally responsible caregiver, or has been
7 designated by a legally responsible caregiver, for a
8 person who receives or is eligible to receive:
9 (i) in-home shift nursing services under the Early
10 and Periodic Screening, Diagnostic and Treatment
11 requirement of Medicaid under 42 U.S.C. 1396d(r); or
12 (ii) in-home shift nursing through the home and
13 community-based services waiver program authorized
14 under Section 1915(c) of the Social Security Act for
15 persons who are medically fragile and technology
16 dependent; and
17 (4) is certified pursuant to this Section to perform
18 or to assist in performance of services to and for a person
19 receiving or eligible to receive: (A) in-home shift
20 nursing services under the Early and Periodic Screening,
21 Diagnostic and Treatment requirement of Medicaid under 42
22 U.S.C. 1396d(r); or (B) in-home shift nursing services
23 through the home and community-based services waiver
24 program authorized under Section 1915(c) of the Social
25 Security Act for a designated person or designated persons
26 who are medically fragile and technology dependent and
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1 eligible to receive the services laid out in this Section,
2 including:
3 (i) the same tasks as a certified nursing
4 assistant;
5 (ii) medication administration;
6 (iii) enteral care and therapy; and
7 (iv) other needed services to support the
8 individual as provided by rule.
9 Section 2-15. Certified family health aide program for
10 children and adults.
11 (a) The Department of Public Health, in partnership with
12 the Department of Healthcare and Family Services, may create a
13 certification pathway for a legally responsible caregiver, or
14 a person who has been designated by a legally responsible
15 caregiver, who is seeking certification as a certified family
16 health aide, including the adoption of any necessary rules for
17 the certification process. This certification pathway shall
18 include documentation, in a manner designated by the
19 Department of Public Health, of initial training provided by
20 hospitals licensed in the Hospital Licensing Act, children's
21 community-based health care centers as defined in the
22 Alternative Health Care Delivery Act, or home nursing agencies
23 as defined in the Home Health, Home Services, and Home Nursing
24 Agency Licensing Act.
25 (b) A certified family health aide may only perform
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1 services to and for a person receiving or eligible to receive:
2 (1) in-home shift nursing services under the Early and
3 Periodic Screening, Diagnostic and Treatment benefit
4 requirement of Medicaid under 42 U.S.C. 1396d(r); or
5 (2) in-home shift nursing services through the home
6 and community-based services waiver program authorized
7 under Section 1915(c) of the Social Security Act for
8 persons who are medically fragile and technology
9 dependent.
10 To be eligible for reimbursement as a certified family
11 health aide, a legally responsible caregiver or a person
12 designated by a legally responsible caregiver must meet all
13 certification requirements as set forth in this Section, in
14 Section 5-2.06b of Article V of the Illinois Public Aid Code,
15 and in any applicable administrative rule.
16 (d) The Department of Public Health, in consultation with
17 the Department of Healthcare and Family Services, may adopt
18 rules necessary to implement the provisions of this Act,
19 including, but not limited to, rules requiring background
20 checks for the certified family health aide, establishing the
21 scope of services a certified family health aide can perform,
22 and establishing any utilization controls of services
23 performed by a certified family health aide.
24 Section 2-100. The Alternative Health Care Delivery Act is
25 amended by changing Section 35 as follows:
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1 (210 ILCS 3/35)
2 Sec. 35. Alternative health care models authorized.
3 Notwithstanding any other law to the contrary, alternative
4 health care models described in this Section may be
5 established on a demonstration basis.
6 (1) (Blank).
7 (2) Alternative health care delivery model;
8 postsurgical recovery care center. A postsurgical recovery
9 care center is a designated site which provides
10 postsurgical recovery care for generally healthy patients
11 undergoing surgical procedures that potentially require
12 overnight nursing care, pain control, or observation that
13 would otherwise be provided in an inpatient setting.
14 Patients may be discharged from the postsurgical recovery
15 care center in less than 24 hours if the attending
16 physician or the facility's medical director believes the
17 patient has recovered enough to be discharged. A
18 postsurgical recovery care center is either freestanding
19 or a defined unit of an ambulatory surgical treatment
20 center or hospital. No facility, or portion of a facility,
21 may participate in a demonstration program as a
22 postsurgical recovery care center unless the facility has
23 been licensed as an ambulatory surgical treatment center
24 or hospital for at least 2 years before August 20, 1993
25 (the effective date of Public Act 88-441). The maximum
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1 length of stay for patients in a postsurgical recovery
2 care center is not to exceed 48 hours unless the treating
3 physician requests an extension of time from the recovery
4 center's medical director on the basis of medical or
5 clinical documentation that an additional care period is
6 required for the recovery of a patient and the medical
7 director approves the extension of time. In no case,
8 however, shall a patient's length of stay in a
9 postsurgical recovery care center be longer than 72 hours.
10 If a patient requires an additional care period after the
11 expiration of the 72-hour limit, the patient shall be
12 transferred to an appropriate facility. Reports on
13 variances from the 24-hour or 48-hour limit shall be sent
14 to the Department for its evaluation. The reports shall,
15 before submission to the Department, have removed from
16 them all patient and physician identifiers. Blood products
17 may be administered in the postsurgical recovery care
18 center model. In order to handle cases of complications,
19 emergencies, or exigent circumstances, every postsurgical
20 recovery care center as defined in this paragraph shall
21 maintain a contractual relationship, including a transfer
22 agreement, with a general acute care hospital. A
23 postsurgical recovery care center shall be no larger than
24 20 beds. A postsurgical recovery care center shall be
25 located within 15 minutes travel time from the general
26 acute care hospital with which the center maintains a
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1 contractual relationship, including a transfer agreement,
2 as required under this paragraph.
3 No postsurgical recovery care center shall
4 discriminate against any patient requiring treatment
5 because of the source of payment for services, including
6 Medicare and Medicaid recipients.
7 The Department shall adopt rules to implement the
8 provisions of Public Act 88-441 concerning postsurgical
9 recovery care centers within 9 months after August 20,
10 1993. Notwithstanding any other law to the contrary, a
11 postsurgical recovery care center model may provide sleep
12 laboratory or similar sleep studies in accordance with
13 applicable State and federal laws and regulations.
14 (3) Alternative health care delivery model; children's
15 community-based health care center. A children's
16 community-based health care center model is a designated
17 site that provides nursing care, clinical support
18 services, and therapies for a period of one to 14 days for
19 short-term stays and 120 days to facilitate transitions to
20 home or other appropriate settings for medically fragile
21 children, technology dependent children, and children with
22 special health care needs who are deemed clinically stable
23 by a physician and are younger than 22 years of age. This
24 care is to be provided in a home-like environment that
25 serves no more than 12 children at a time, except that a
26 children's community-based health care center in existence
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1 on the effective date of this amendatory Act of the 100th
2 General Assembly that is located in Chicago on grade level
3 for Life Safety Code purposes may provide care to no more
4 than 16 children at a time. Children's community-based
5 health care center services must be available through the
6 model to all families, including those whose care is paid
7 for through the Department of Healthcare and Family
8 Services, the Department of Children and Family Services,
9 the Department of Human Services, and insurance companies
10 who cover home health care services or private duty
11 nursing care in the home.
12 Each children's community-based health care center
13 model location shall be physically separate and apart from
14 any other facility licensed by the Department of Public
15 Health under this or any other Act and shall provide the
16 following services: respite care, registered nursing or
17 licensed practical nursing care, transitional care to
18 facilitate home placement or other appropriate settings
19 and reunite families, medical day care, weekend camps, and
20 diagnostic studies typically done in the home setting.
21 A children's community-based health care center may
22 provide initial training, prior to home placement for, and
23 shall keep records in a manner designated by the
24 Department regarding, the certified family health aide, as
25 defined in the Certified Family Health Aide Program for
26 Children and Adults Act, identified as the legally
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1 responsible caregiver or designated by a legally
2 responsible caregiver for the medical care of an
3 individual who receives or is eligible to receive:
4 (i) in-home shift nursing services under the Early
5 and Periodic Screening, Diagnostic and Treatment
6 requirement of Medicaid under 42 U.S.C. 1396d(r); or
7 (ii) in-home shift nursing through the home and
8 community-based services waiver program authorized
9 under Section 1915(c) of the Social Security Act for
10 persons who are medically fragile and technology
11 dependent.
12 Coverage for the services provided by the Department
13 of Healthcare and Family Services under this paragraph (3)
14 is contingent upon federal waiver approval and is provided
15 only to Medicaid eligible clients participating in the
16 home and community based services waiver designated in
17 Section 1915(c) of the Social Security Act for medically
18 frail and technologically dependent children or children
19 in Department of Children and Family Services foster care
20 who receive home health benefits.
21 (4) Alternative health care delivery model; community
22 based residential rehabilitation center. A community-based
23 residential rehabilitation center model is a designated
24 site that provides rehabilitation or support, or both, for
25 persons who have experienced severe brain injury, who are
26 medically stable, and who no longer require acute
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1 rehabilitative care or intense medical or nursing
2 services. The average length of stay in a community-based
3 residential rehabilitation center shall not exceed 4
4 months. As an integral part of the services provided,
5 individuals are housed in a supervised living setting
6 while having immediate access to the community. The
7 residential rehabilitation center authorized by the
8 Department may have more than one residence included under
9 the license. A residence may be no larger than 12 beds and
10 shall be located as an integral part of the community. Day
11 treatment or individualized outpatient services shall be
12 provided for persons who reside in their own home.
13 Functional outcome goals shall be established for each
14 individual. Services shall include, but are not limited
15 to, case management, training and assistance with
16 activities of daily living, nursing consultation,
17 traditional therapies (physical, occupational, speech),
18 functional interventions in the residence and community
19 (job placement, shopping, banking, recreation),
20 counseling, self-management strategies, productive
21 activities, and multiple opportunities for skill
22 acquisition and practice throughout the day. The design of
23 individualized program plans shall be consistent with the
24 outcome goals that are established for each resident. The
25 programs provided in this setting shall be accredited by
26 the Commission on Accreditation of Rehabilitation
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1 Facilities (CARF). The program shall have been accredited
2 by CARF as a Brain Injury Community-Integrative Program
3 for at least 3 years.
4 (5) Alternative health care delivery model;
5 Alzheimer's disease management center. An Alzheimer's
6 disease management center model is a designated site that
7 provides a safe and secure setting for care of persons
8 diagnosed with Alzheimer's disease. An Alzheimer's disease
9 management center model shall be a facility separate from
10 any other facility licensed by the Department of Public
11 Health under this or any other Act. An Alzheimer's disease
12 management center shall conduct and document an assessment
13 of each resident every 6 months. The assessment shall
14 include an evaluation of daily functioning, cognitive
15 status, other medical conditions, and behavioral problems.
16 An Alzheimer's disease management center shall develop and
17 implement an ongoing treatment plan for each resident. The
18 treatment plan shall have defined goals. The Alzheimer's
19 disease management center shall treat behavioral problems
20 and mood disorders using nonpharmacologic approaches such
21 as environmental modification, task simplification, and
22 other appropriate activities. All staff must have
23 necessary training to care for all stages of Alzheimer's
24 Disease. An Alzheimer's disease management center shall
25 provide education and support for residents and
26 caregivers. The education and support shall include
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1 referrals to support organizations for educational
2 materials on community resources, support groups, legal
3 and financial issues, respite care, and future care needs
4 and options. The education and support shall also include
5 a discussion of the resident's need to make advance
6 directives and to identify surrogates for medical and
7 legal decision-making. The provisions of this paragraph
8 establish the minimum level of services that must be
9 provided by an Alzheimer's disease management center. An
10 Alzheimer's disease management center model shall have no
11 more than 100 residents. Nothing in this paragraph (5)
12 shall be construed as prohibiting a person or facility
13 from providing services and care to persons with
14 Alzheimer's disease as otherwise authorized under State
15 law.
16 (6) Alternative health care delivery model; birth
17 center. A birth center shall be exclusively dedicated to
18 serving the childbirth-related needs of women and their
19 newborns and shall have no more than 10 beds. A birth
20 center is a designated site that is away from the mother's
21 usual place of residence and in which births are planned
22 to occur following a normal, uncomplicated, and low-risk
23 pregnancy. A birth center shall offer prenatal care and
24 community education services and shall coordinate these
25 services with other health care services available in the
26 community.
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1 (A) A birth center shall not be separately
2 licensed if it is one of the following:
3 (1) A part of a hospital; or
4 (2) A freestanding facility that is physically
5 distinct from a hospital but is operated under a
6 license issued to a hospital under the Hospital
7 Licensing Act.
8 (B) A separate birth center license shall be
9 required if the birth center is operated as:
10 (1) A part of the operation of a federally
11 qualified health center as designated by the
12 United States Department of Health and Human
13 Services; or
14 (2) A facility other than one described in
15 subparagraph (A)(1), (A)(2), or (B)(1) of this
16 paragraph (6) whose costs are reimbursable under
17 Title XIX of the federal Social Security Act.
18 In adopting rules for birth centers, the Department
19 shall consider: the American Association of Birth Centers'
20 Standards for Freestanding Birth Centers; the American
21 Academy of Pediatrics/American College of Obstetricians
22 and Gynecologists Guidelines for Perinatal Care; and the
23 Regionalized Perinatal Health Care Code. The Department's
24 rules shall stipulate the eligibility criteria for birth
25 center admission. The Department's rules shall stipulate
26 the necessary equipment for emergency care according to
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1 the American Association of Birth Centers' standards and
2 any additional equipment deemed necessary by the
3 Department. The Department's rules shall provide for a
4 time period within which each birth center not part of a
5 hospital must become accredited by either the Commission
6 for the Accreditation of Freestanding Birth Centers or The
7 Joint Commission.
8 A birth center shall be certified to participate in
9 the Medicare and Medicaid programs under Titles XVIII and
10 XIX, respectively, of the federal Social Security Act. To
11 the extent necessary, the Illinois Department of
12 Healthcare and Family Services shall apply for a waiver
13 from the United States Health Care Financing
14 Administration to allow birth centers to be reimbursed
15 under Title XIX of the federal Social Security Act.
16 A birth center that is not operated under a hospital
17 license shall be located within a ground travel time
18 distance from the general acute care hospital with which
19 the birth center maintains a contractual relationship,
20 including a transfer agreement, as required under this
21 paragraph, that allows for an emergency caesarian delivery
22 to be started within 30 minutes of the decision a
23 caesarian delivery is necessary. A birth center operating
24 under a hospital license shall be located within a ground
25 travel time distance from the licensed hospital that
26 allows for an emergency caesarian delivery to be started
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1 within 30 minutes of the decision a caesarian delivery is
2 necessary.
3 The services of a medical director physician, licensed
4 to practice medicine in all its branches, who is certified
5 or eligible for certification by the American College of
6 Obstetricians and Gynecologists or the American Board of
7 Osteopathic Obstetricians and Gynecologists or has
8 hospital obstetrical privileges are required in birth
9 centers. The medical director in consultation with the
10 Director of Nursing and Midwifery Services shall
11 coordinate the clinical staff and overall provision of
12 patient care. The medical director or his or her physician
13 designee shall be available on the premises or within a
14 close proximity as defined by rule. The medical director
15 and the Director of Nursing and Midwifery Services shall
16 jointly develop and approve policies defining the criteria
17 to determine which pregnancies are accepted as normal,
18 uncomplicated, and low-risk, and the anesthesia services
19 available at the center. No general anesthesia may be
20 administered at the center.
21 If a birth center employs certified nurse midwives, a
22 certified nurse midwife shall be the Director of Nursing
23 and Midwifery Services who is responsible for the
24 development of policies and procedures for services as
25 provided by Department rules.
26 An obstetrician, family practitioner, or certified
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1 nurse midwife shall attend each woman in labor from the
2 time of admission through birth and throughout the
3 immediate postpartum period. Attendance may be delegated
4 only to another physician or certified nurse midwife.
5 Additionally, a second staff person shall also be present
6 at each birth who is licensed or certified in Illinois in a
7 health-related field and under the supervision of the
8 physician or certified nurse midwife in attendance, has
9 specialized training in labor and delivery techniques and
10 care of newborns, and receives planned and ongoing
11 training as needed to perform assigned duties effectively.
12 The maximum length of stay in a birth center shall be
13 consistent with existing State laws allowing a 48-hour
14 stay or appropriate post-delivery care, if discharged
15 earlier than 48 hours.
16 A birth center shall participate in the Illinois
17 Perinatal System under the Developmental Disability
18 Prevention Act. At a minimum, this participation shall
19 require a birth center to establish a letter of agreement
20 with a hospital designated under the Perinatal System. A
21 hospital that operates or has a letter of agreement with a
22 birth center shall include the birth center under its
23 maternity service plan under the Hospital Licensing Act
24 and shall include the birth center in the hospital's
25 letter of agreement with its regional perinatal center.
26 A birth center may not discriminate against any
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1 patient requiring treatment because of the source of
2 payment for services, including Medicare and Medicaid
3 recipients.
4 No general anesthesia and no surgery may be performed
5 at a birth center. The Department may by rule add birth
6 center patient eligibility criteria or standards as it
7 deems necessary. The Department shall by rule require each
8 birth center to report the information which the
9 Department shall make publicly available, which shall
10 include, but is not limited to, the following:
11 (i) Birth center ownership.
12 (ii) Sources of payment for services.
13 (iii) Utilization data involving patient length of
14 stay.
15 (iv) Admissions and discharges.
16 (v) Complications.
17 (vi) Transfers.
18 (vii) Unusual incidents.
19 (viii) Deaths.
20 (ix) Any other publicly reported data required
21 under the Illinois Consumer Guide.
22 (x) Post-discharge patient status data where
23 patients are followed for 14 days after discharge from
24 the birth center to determine whether the mother or
25 baby developed a complication or infection.
26 Within 9 months after the effective date of this
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1 amendatory Act of the 95th General Assembly, the
2 Department shall adopt rules that are developed with
3 consideration of: the American Association of Birth
4 Centers' Standards for Freestanding Birth Centers; the
5 American Academy of Pediatrics/American College of
6 Obstetricians and Gynecologists Guidelines for Perinatal
7 Care; and the Regionalized Perinatal Health Care Code.
8 The Department shall adopt other rules as necessary to
9 implement the provisions of this amendatory Act of the
10 95th General Assembly within 9 months after the effective
11 date of this amendatory Act of the 95th General Assembly.
12 (Source: P.A. 100-518, eff. 12-8-17 (see Section 5 of P.A.
13 100-558 for the effective date of changes made by P.A.
14 100-518).)
15 Section 2-105. The Home Health, Home Services, and Home
16 Nursing Agency Licensing Act is amended by changing Section
17 2.11 and by adding Section 2.13 as follows:
18 (210 ILCS 55/2.11)
19 Sec. 2.11. "Home nursing agency" means an agency that
20 provides services directly, or acts as a placement agency, in
21 order to deliver skilled nursing and home health aide services
22 to persons in their personal residences or a certified family
23 health aide, as defined by the Certified Family Health Aide
24 Program for Children and Adults Act, for individuals receiving
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1 or eligible to receive: (1) in-home shift nursing services
2 under the Early and Periodic Screening, Diagnostic and
3 Treatment requirement of Medicaid under 42 U.S.C. 1396d(r); or
4 (2) in-home shift nursing services through the home and
5 community-based services waiver program authorized under
6 Section 1915(c) of the Social Security Act for persons who are
7 medically fragile and technology dependent. A home nursing
8 agency provides services that would require a licensed nurse
9 to perform. Home health aide services are provided under the
10 direction of a registered professional nurse or advanced
11 practice registered nurse. A home nursing agency does not
12 require licensure as a home health agency under this Act.
13 "Home nursing agency" does not include an individually
14 licensed nurse acting as a private contractor or a person that
15 provides or procures temporary employment in health care
16 facilities, as defined in the Nurse Agency Licensing Act.
17 (Source: P.A. 100-513, eff. 1-1-18.)
18 (210 ILCS 55/2.13 new)
19 Sec. 2.13. Certified family health aide. A home nursing
20 agency may provide initial and ongoing training for, and shall
21 keep records in a manner designated by the Department
22 regarding, the certified family health aide, as defined in the
23 Certified Family Health Aide Program for Children and Adults
24 Act, identified as the legally responsible caregiver or
25 designated by the legally responsible caregiver for an
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1 individual who receives or is eligible to receive:
2 (1) in-home shift nursing services under the Early and
3 Periodic Screening, Diagnostic and Treatment requirement
4 of Medicaid under 42 U.S.C. 1396d(r); or
5 (2) in-home shift nursing through the home and
6 community-based services waiver program authorized under
7 Section 1915(c) of the Social Security Act for persons who
8 are medically fragile and technology dependent.
9 Section 2-110. The Hospital Licensing Act is amended by
10 adding Section 17 as follows:
11 (210 ILCS 85/17 new)
12 Sec. 17. Certified family health aide. Hospitals managing
13 the care of an individual to be discharged under the care of a
14 home nursing agency may provide initial training, and shall
15 document in a manner designated by the Department, for the
16 certified family health aide, as defined in the Certified
17 Family Health Aide Program for Children and Adults Act,
18 identified as the legally responsible caregiver or designated
19 by a legally responsible caregiver for an individual who
20 receives or is eligible to receive: (1) in-home shift nursing
21 services under the Early and Periodic Screening, Diagnostic
22 and Treatment requirement of Medicaid under 42 U.S.C. 1396d(r)
23 or (2) in-home shift nursing through the home and
24 community-based services waiver program authorized under
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1 Section 1915(c) of the Social Security Act for persons who are
2 medically fragile and technology dependent.
3 Section 2-115. The Nurse Practice Act is amended by
4 changing Section 50-15 as follows:
5 (225 ILCS 65/50-15) (was 225 ILCS 65/5-15)
6 (Section scheduled to be repealed on January 1, 2028)
7 Sec. 50-15. Policy; application of Act.
8 (a) For the protection of life and the promotion of
9 health, and the prevention of illness and communicable
10 diseases, any person practicing or offering to practice
11 advanced, professional, or practical nursing in Illinois shall
12 submit evidence that he or she is qualified to practice, and
13 shall be licensed as provided under this Act. No person shall
14 practice or offer to practice advanced, professional, or
15 practical nursing in Illinois or use any title, sign, card or
16 device to indicate that such a person is practicing
17 professional or practical nursing unless such person has been
18 licensed under the provisions of this Act.
19 (b) This Act does not prohibit the following:
20 (1) The practice of nursing in Federal employment in
21 the discharge of the employee's duties by a person who is
22 employed by the United States government or any bureau,
23 division or agency thereof and is a legally qualified and
24 licensed nurse of another state or territory and not in
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1 conflict with Sections 50-50, 55-10, 60-10, and 70-5 of
2 this Act.
3 (2) Nursing that is included in the program of study
4 by students enrolled in programs of nursing or in current
5 nurse practice update courses approved by the Department.
6 (3) The furnishing of nursing assistance in an
7 emergency.
8 (4) The practice of nursing by a nurse who holds an
9 active license in another state when providing services to
10 patients in Illinois during a bonafide emergency or in
11 immediate preparation for or during interstate transit.
12 (5) The incidental care of the sick by members of the
13 family, domestic servants or housekeepers, or care of the
14 sick where treatment is by prayer or spiritual means.
15 (6) Persons from being employed as unlicensed
16 assistive personnel in private homes, long term care
17 facilities, nurseries, hospitals or other institutions.
18 (7) The practice of practical nursing by one who is a
19 licensed practical nurse under the laws of another U.S.
20 jurisdiction and has applied in writing to the Department,
21 in form and substance satisfactory to the Department, for
22 a license as a licensed practical nurse and who is
23 qualified to receive such license under this Act, until
24 (i) the expiration of 6 months after the filing of such
25 written application, (ii) the withdrawal of such
26 application, or (iii) the denial of such application by
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1 the Department.
2 (8) The practice of advanced practice registered
3 nursing by one who is an advanced practice registered
4 nurse under the laws of another United States jurisdiction
5 or a foreign jurisdiction and has applied in writing to
6 the Department, in form and substance satisfactory to the
7 Department, for a license as an advanced practice
8 registered nurse and who is qualified to receive such
9 license under this Act, until (i) the expiration of 6
10 months after the filing of such written application, (ii)
11 the withdrawal of such application, or (iii) the denial of
12 such application by the Department.
13 (9) The practice of professional nursing by one who is
14 a registered professional nurse under the laws of another
15 United States jurisdiction or a foreign jurisdiction and
16 has applied in writing to the Department, in form and
17 substance satisfactory to the Department, for a license as
18 a registered professional nurse and who is qualified to
19 receive such license under Section 55-10, until (1) the
20 expiration of 6 months after the filing of such written
21 application, (2) the withdrawal of such application, or
22 (3) the denial of such application by the Department.
23 (10) The practice of professional nursing that is
24 included in a program of study by one who is a registered
25 professional nurse under the laws of another United States
26 jurisdiction or a foreign jurisdiction and who is enrolled
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1 in a graduate nursing education program or a program for
2 the completion of a baccalaureate nursing degree in this
3 State, which includes clinical supervision by faculty as
4 determined by the educational institution offering the
5 program and the health care organization where the
6 practice of nursing occurs.
7 (11) Any person licensed in this State under any other
8 Act from engaging in the practice for which she or he is
9 licensed.
10 (12) Delegation to authorized direct care staff
11 trained under Section 15.4 of the Mental Health and
12 Developmental Disabilities Administrative Act consistent
13 with the policies of the Department.
14 (13) (Blank).
15 (14) County correctional personnel from delivering
16 prepackaged medication for self-administration to an
17 individual detainee in a correctional facility.
18 (15) The practice of relevant care by a legally
19 responsible caregiver or a person designated by a legally
20 responsible caregiver who has been certified as a
21 certified family health aide, as defined in the Certified
22 Family Health Aide Program for Children and Adults Act, to
23 perform for a person who receives or is eligible to
24 receive: (i) in-home shift nursing services under the
25 Early and Periodic Screening, Diagnostic and Treatment
26 requirement of Medicaid under 42 U.S.C. 1396d(r); or (ii)
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1 in-home shift nursing services through the home and
2 community-based services waiver program authorized under
3 Section 1915(c) of the Social Security Act for persons who
4 are medically fragile and technology dependent.
5 Nothing in this Act shall be construed to limit the
6 delegation of tasks or duties by a physician, dentist, or
7 podiatric physician to a licensed practical nurse, a
8 registered professional nurse, or other persons.
9 (Source: P.A. 100-513, eff. 1-1-18.)
10 Section 2-120. The Illinois Public Aid Code is amended by
11 adding Section 5-2.06b as follows:
12 (305 ILCS 5/5-2.06b new)
13 Sec. 5-2.06b. Certified family health aide program for
14 children and adults.
15 (a) The Department of Healthcare and Family Services may
16 seek any federal approval from the Centers for Medicare and
17 Medicaid Services necessary to reimburse a legally responsible
18 caregiver or a person designated by a legally responsible
19 caregiver, as defined in the Certified Family Health Aide
20 Program for Children and Adults Act, who has achieved
21 certification as a certified family health aide to perform or
22 assist in performance of services for a person who receives or
23 is eligible to receive: (1) in-home shift nursing services
24 under the Early and Periodic Screening, Diagnostic and
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1 Treatment requirement of Medicaid under 42 U.S.C. 1396d(r); or
2 (2) the home and community-based services waiver program
3 authorized under Section 1915(c) of the Social Security Act
4 for a designated person or designated persons who are
5 medically fragile and technology dependent. Implementation of
6 any and all parts of the certified family health aide program
7 is subject to the Department of Healthcare and Family Services
8 receiving all necessary federal approval. If the Department of
9 Healthcare and Family Services receives all necessary federal
10 approval the Department may adopt rules in consultation with
11 the Department of Public Health to specify the federally
12 approved services eligible for reimbursement under the
13 certified family health aide certification and to adopt any
14 other policies or procedures necessary to implement this
15 Section.
16 (b) The Department of Healthcare and Family Services, in
17 partnership with the Department of Public Health, may consult
18 with stakeholders for expertise regarding implementation of
19 the certified family health aide program. Stakeholders may
20 include, the University of Illinois at Chicago, Division of
21 Specialized Care for Children, home nurse agencies, a
22 physician with medical experience with the population being
23 served by the program, children's hospitals, a legally
24 responsible caregiver as described in item (3) of Section 10
25 of the Certified Family Health Aide Program for Children and
26 Adults Act, and a Children's Community-Based Health Care
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1 Clinic.
2 (c) Subject to federal approval, the Department of
3 Healthcare and Family Services may adopt rules to disregard
4 income earned by a legally responsible caregiver in the
5 performance of or assisting in the performance of services for
6 a person receiving or eligible to receive: (1) in-home shift
7 nursing services under the Early and Periodic Screening,
8 Diagnostic and Treatment requirement of Medicaid under 42
9 U.S.C. 1396d(r); or (2) the home and community-based services
10 waiver program authorized under Section 1915(c) of the Social
11 Security Act for a designated person or designated persons who
12 are medically fragile and technology dependent, when
13 determining the child's eligibility for medical assistance
14 under the Medical Assistance-No Grant (MANG (AABD)) Income
15 Standard.
16 ARTICLE 5.
17 Section 5-5. The Illinois Public Aid Code is amended by
18 adding Sections 5-18.6 and 5-18.7 as follows:
19 (305 ILCS 5/5-18.6 new)
20 Sec. 5-18.6. Doula policies; hospitals and birthing
21 centers.
22 (a) Recognizing the importance that doulas provide in the
23 support and advocacy for pregnant persons, within 6 months
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1 after this amendatory Act of the 104th General Assembly, all
2 hospitals with licensed obstetric beds and birthing centers
3 shall adopt and maintain written policies and procedures to
4 permit a patient enrolled in the medical assistance program to
5 have an Illinois Medicaid certified and enrolled doula of the
6 patient's choice accompany the patient within the facility's
7 premises for the purposes of providing support before, during,
8 and after labor and childbirth.
9 (1) An Illinois Medicaid certified and enrolled doula
10 shall not be counted as a support person or against the
11 guest quota before, during, or after childbirth.
12 (2) Each applicable facility shall post a summary of
13 the facility's policies and procedures adopted in
14 accordance with this subsection on its website, including
15 contact information to facilitate communication between
16 the facility and Illinois Medicaid enrolled doulas and
17 doula organizations.
18 (b) Nothing in this Section shall be construed to provide
19 a doula with access to a patient when that access is
20 inconsistent with generally accepted medical standards or
21 practices.
22 (c) Nothing in this Section is intended to expand or limit
23 the malpractice liability of a hospital beyond the limits
24 existing in current Illinois statutory and common law;
25 however, no hospital shall be liable for any act or omission
26 resulting from the provision of services by any doula solely
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1 on the basis that the hospital permitted an Illinois Medicaid
2 certified and enrolled doula of the patient's choice to
3 accompany the patient within the facility's premises for the
4 purposes of providing support before, during, and after labor
5 and childbirth. The hospital and Illinois Medicaid certified
6 and enrolled doula providing care are responsible for their
7 own acts and omissions.
8 (d) At the request of the hospital or birthing facility,
9 Illinois Medicaid enrolled doulas must provide written
10 acknowledgment of Illinois Medicaid doula certification and
11 enrollment in the medical assistance program.
12 (305 ILCS 5/5-18.7 new)
13 Sec. 5-18.7. Standing recommendations. The Department of
14 Healthcare and Family Services and the Department of Public
15 Health may establish standing recommendations to meet Centers
16 for Medicare and Medicaid Services requirements and ensure
17 access to preventive services, including Medicaid-covered
18 maternal and reproductive health supports and services, such
19 as, but not limited to, doulas, lactation consultants, home
20 visitors, community health workers, and 1115 Waiver services.
21 No employee of the Department of Healthcare and Family
22 Services or the Department of Public Health issuing a standing
23 recommendation in accordance with this Section shall, as a
24 result of the employee's acts or omissions in issuing the
25 standing recommendation, be subject to (i) any disciplinary or
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1 other adverse action under the Medical Practice Act of 1987,
2 (ii) any civil liability, or (iii) any criminal liability.
3 ARTICLE 10.
4 Section 10-5. The Illinois Public Aid Code is amended by
5 changing Section 5-2 as follows:
6 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
7 Sec. 5-2. Classes of persons eligible. Medical assistance
8 under this Article shall be available to any of the following
9 classes of persons in respect to whom a plan for coverage has
10 been submitted to the Governor by the Illinois Department and
11 approved by him. If changes made in this Section 5-2 require
12 federal approval, they shall not take effect until such
13 approval has been received:
14 1. Recipients of basic maintenance grants under
15 Articles III and IV.
16 2. Beginning January 1, 2014, persons otherwise
17 eligible for basic maintenance under Article III,
18 excluding any eligibility requirements that are
19 inconsistent with any federal law or federal regulation,
20 as interpreted by the U.S. Department of Health and Human
21 Services, but who fail to qualify thereunder on the basis
22 of need, and who have insufficient income and resources to
23 meet the costs of necessary medical care, including, but
SB2437 Enrolled - 31 - LRB104 10548 KTG 20624 b
1 not limited to, the following:
2 (a) All persons otherwise eligible for basic
3 maintenance under Article III but who fail to qualify
4 under that Article on the basis of need and who meet
5 either of the following requirements:
6 (i) their income, as determined by the
7 Illinois Department in accordance with any federal
8 requirements, is equal to or less than 100% of the
9 federal poverty level; or
10 (ii) their income, after the deduction of
11 costs incurred for medical care and for other
12 types of remedial care, is equal to or less than
13 100% of the federal poverty level.
14 (b) (Blank).
15 3. (Blank).
16 4. Persons not eligible under any of the preceding
17 paragraphs who fall sick, are injured, or die, not having
18 sufficient money, property or other resources to meet the
19 costs of necessary medical care or funeral and burial
20 expenses.
21 5.(a) Beginning January 1, 2020, individuals during
22 pregnancy and during the 12-month period beginning on the
23 last day of the pregnancy, together with their infants,
24 whose income is at or below 200% of the federal poverty
25 level. Until September 30, 2019, or sooner if the
26 maintenance of effort requirements under the Patient
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1 Protection and Affordable Care Act are eliminated or may
2 be waived before then, individuals during pregnancy and
3 during the 12-month period beginning on the last day of
4 the pregnancy, whose countable monthly income, after the
5 deduction of costs incurred for medical care and for other
6 types of remedial care as specified in administrative
7 rule, is equal to or less than the Medical Assistance-No
8 Grant(C) (MANG(C)) Income Standard in effect on April 1,
9 2013 as set forth in administrative rule.
10 (b) The plan for coverage shall provide ambulatory
11 prenatal care to pregnant individuals during a presumptive
12 eligibility period and establish an income eligibility
13 standard that is equal to 200% of the federal poverty
14 level, provided that costs incurred for medical care are
15 not taken into account in determining such income
16 eligibility.
17 (c) The Illinois Department may conduct a
18 demonstration in at least one county that will provide
19 medical assistance to pregnant individuals together with
20 their infants and children up to one year of age, where the
21 income eligibility standard is set up to 185% of the
22 nonfarm income official poverty line, as defined by the
23 federal Office of Management and Budget. The Illinois
24 Department shall seek and obtain necessary authorization
25 provided under federal law to implement such a
26 demonstration. Such demonstration may establish resource
SB2437 Enrolled - 33 - LRB104 10548 KTG 20624 b
1 standards that are not more restrictive than those
2 established under Article IV of this Code.
3 6. (a) Subject to federal approval, children younger
4 than age 19 when countable income is at or below 313% of
5 the federal poverty level, as determined by the Department
6 and in accordance with all applicable federal
7 requirements. The Department is authorized to adopt
8 emergency rules to implement the changes made to this
9 paragraph by Public Act 102-43. Until September 30, 2019,
10 or sooner if the maintenance of effort requirements under
11 the Patient Protection and Affordable Care Act are
12 eliminated or may be waived before then, children younger
13 than age 19 whose countable monthly income, after the
14 deduction of costs incurred for medical care and for other
15 types of remedial care as specified in administrative
16 rule, is equal to or less than the Medical Assistance-No
17 Grant(C) (MANG(C)) Income Standard in effect on April 1,
18 2013 as set forth in administrative rule.
19 (b) Children and youth who are under temporary custody
20 or guardianship of the Department of Children and Family
21 Services or who receive financial assistance in support of
22 an adoption or guardianship placement from the Department
23 of Children and Family Services.
24 7. (Blank).
25 8. As required under federal law, persons who are
26 eligible for Transitional Medical Assistance as a result
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1 of an increase in earnings or child or spousal support
2 received. The plan for coverage for this class of persons
3 shall:
4 (a) extend the medical assistance coverage to the
5 extent required by federal law; and
6 (b) offer persons who have initially received 6
7 months of the coverage provided in paragraph (a)
8 above, the option of receiving an additional 6 months
9 of coverage, subject to the following:
10 (i) such coverage shall be pursuant to
11 provisions of the federal Social Security Act;
12 (ii) such coverage shall include all services
13 covered under Illinois' State Medicaid Plan;
14 (iii) no premium shall be charged for such
15 coverage; and
16 (iv) such coverage shall be suspended in the
17 event of a person's failure without good cause to
18 file in a timely fashion reports required for this
19 coverage under the Social Security Act and
20 coverage shall be reinstated upon the filing of
21 such reports if the person remains otherwise
22 eligible.
23 9. Persons with acquired immunodeficiency syndrome
24 (AIDS) or with AIDS-related conditions with respect to
25 whom there has been a determination that but for home or
26 community-based services such individuals would require
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1 the level of care provided in an inpatient hospital,
2 skilled nursing facility or intermediate care facility the
3 cost of which is reimbursed under this Article. Assistance
4 shall be provided to such persons to the maximum extent
5 permitted under Title XIX of the Federal Social Security
6 Act.
7 10. Participants in the long-term care insurance
8 partnership program established under the Illinois
9 Long-Term Care Partnership Program Act who meet the
10 qualifications for protection of resources described in
11 Section 15 of that Act.
12 11. Persons with disabilities who are employed and
13 eligible for Medicaid, pursuant to Section
14 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
15 subject to federal approval, persons with a medically
16 improved disability who are employed and eligible for
17 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
18 the Social Security Act, as provided by the Illinois
19 Department by rule. In establishing eligibility standards
20 under this paragraph 11, the Department shall, subject to
21 federal approval:
22 (a) set the income eligibility standard at not
23 lower than 350% of the federal poverty level;
24 (b) exempt retirement accounts that the person
25 cannot access without penalty before the age of 59
26 1/2, and medical savings accounts established pursuant
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1 to 26 U.S.C. 220;
2 (c) allow non-exempt assets up to $25,000 as to
3 those assets accumulated during periods of eligibility
4 under this paragraph 11; and
5 (d) continue to apply subparagraphs (b) and (c) in
6 determining the eligibility of the person under this
7 Article even if the person loses eligibility under
8 this paragraph 11.
9 12. Subject to federal approval, persons who are
10 eligible for medical assistance coverage under applicable
11 provisions of the federal Social Security Act and the
12 federal Breast and Cervical Cancer Prevention and
13 Treatment Act of 2000. Those eligible persons are defined
14 to include, but not be limited to, the following persons:
15 (1) persons who have been screened for breast or
16 cervical cancer under the U.S. Centers for Disease
17 Control and Prevention Breast and Cervical Cancer
18 Program established under Title XV of the federal
19 Public Health Service Act in accordance with the
20 requirements of Section 1504 of that Act as
21 administered by the Illinois Department of Public
22 Health; and
23 (2) persons whose screenings under the above
24 program were funded in whole or in part by funds
25 appropriated to the Illinois Department of Public
26 Health for breast or cervical cancer screening.
SB2437 Enrolled - 37 - LRB104 10548 KTG 20624 b
1 "Medical assistance" under this paragraph 12 shall be
2 identical to the benefits provided under the State's
3 approved plan under Title XIX of the Social Security Act.
4 The Department must request federal approval of the
5 coverage under this paragraph 12 within 30 days after July
6 3, 2001 (the effective date of Public Act 92-47).
7 In addition to the persons who are eligible for
8 medical assistance pursuant to subparagraphs (1) and (2)
9 of this paragraph 12, and to be paid from funds
10 appropriated to the Department for its medical programs,
11 any uninsured person as defined by the Department in rules
12 residing in Illinois who is younger than 65 years of age,
13 who has been screened for breast and cervical cancer in
14 accordance with standards and procedures adopted by the
15 Department of Public Health for screening, and who is
16 referred to the Department by the Department of Public
17 Health as being in need of treatment for breast or
18 cervical cancer is eligible for medical assistance
19 benefits that are consistent with the benefits provided to
20 those persons described in subparagraphs (1) and (2).
21 Medical assistance coverage for the persons who are
22 eligible under the preceding sentence is not dependent on
23 federal approval, but federal moneys may be used to pay
24 for services provided under that coverage upon federal
25 approval.
26 13. Subject to appropriation and to federal approval,
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1 persons living with HIV/AIDS who are not otherwise
2 eligible under this Article and who qualify for services
3 covered under Section 5-5.04 as provided by the Illinois
4 Department by rule.
5 14. Subject to the availability of funds for this
6 purpose, the Department may provide coverage under this
7 Article to persons who
8 (a) reside in Illinois; who
9 (b) are not eligible under any of the preceding
10 paragraphs of this Section; and who
11 (c) meet the income guidelines of paragraph 2(a)
12 of this Section; and
13 (d) meet one of the following conditions:
14 (i) have filed an application for asylum
15 status under 8 U.S.C. 1158 that is pending with
16 the appropriate federal agency or have a pending
17 appeal of such an application pending before the
18 federal Department of Homeland Security or on
19 appeal before a court of competent jurisdiction
20 and are represented either by counsel or by an
21 advocate accredited by the appropriate federal
22 agency Department of Homeland Security and
23 employed by a not-for-profit organization in
24 regard to that application or appeal; , or
25 (ii) are receiving services through a
26 federally funded torture treatment center;
SB2437 Enrolled - 39 - LRB104 10548 KTG 20624 b
1 (iii) have filed a pending application for T
2 nonimmigrant status pursuant to 8 U.S.C.
3 1101(a)(15)(T);
4 (iv) have filed a pending application for U
5 nonimmigrant status pursuant to 8 U.S.C.
6 1101(a)(15)(U); or
7 (v) have filed as a derivative family member
8 or are included in the application for item (i),
9 (iii), or (iv) as provided by Department rule.
10 Medical coverage under this paragraph 14 may be
11 provided for up to 24 continuous months from the initial
12 eligibility date so long as an individual continues to
13 satisfy the criteria of this paragraph 14. If an
14 individual has an application or appeal pending regarding
15 an application for asylum, T nonimmigrant status, or U
16 nonimmigrant status before the appropriate federal agency
17 for such applications or appeals Department of Homeland
18 Security, eligibility under this paragraph 14 may be
19 extended until a final decision is rendered with respect
20 to the application or appeal, except that an individual
21 who is approved for a U visa continues to qualify for
22 medical coverage under this paragraph 14 as long as the
23 individual meets all other eligibility criteria on the
24 appeal. The Department shall may adopt rules governing the
25 implementation of this paragraph 14.
26 15. Family Care Eligibility.
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1 (a) On and after July 1, 2012, a parent or other
2 caretaker relative who is 19 years of age or older when
3 countable income is at or below 133% of the federal
4 poverty level. A person may not spend down to become
5 eligible under this paragraph 15.
6 (b) Eligibility shall be reviewed annually.
7 (c) (Blank).
8 (d) (Blank).
9 (e) (Blank).
10 (f) (Blank).
11 (g) (Blank).
12 (h) (Blank).
13 (i) Following termination of an individual's
14 coverage under this paragraph 15, the individual must
15 be determined eligible before the person can be
16 re-enrolled.
17 16. Subject to appropriation, uninsured persons who
18 are not otherwise eligible under this Section who have
19 been certified and referred by the Department of Public
20 Health as having been screened and found to need
21 diagnostic evaluation or treatment, or both diagnostic
22 evaluation and treatment, for prostate or testicular
23 cancer. For the purposes of this paragraph 16, uninsured
24 persons are those who do not have creditable coverage, as
25 defined under the Health Insurance Portability and
26 Accountability Act, or have otherwise exhausted any
SB2437 Enrolled - 41 - LRB104 10548 KTG 20624 b
1 insurance benefits they may have had, for prostate or
2 testicular cancer diagnostic evaluation or treatment, or
3 both diagnostic evaluation and treatment. To be eligible,
4 a person must furnish a Social Security number. A person's
5 assets are exempt from consideration in determining
6 eligibility under this paragraph 16. Such persons shall be
7 eligible for medical assistance under this paragraph 16
8 for so long as they need treatment for the cancer. A person
9 shall be considered to need treatment if, in the opinion
10 of the person's treating physician, the person requires
11 therapy directed toward cure or palliation of prostate or
12 testicular cancer, including recurrent metastatic cancer
13 that is a known or presumed complication of prostate or
14 testicular cancer and complications resulting from the
15 treatment modalities themselves. Persons who require only
16 routine monitoring services are not considered to need
17 treatment. "Medical assistance" under this paragraph 16
18 shall be identical to the benefits provided under the
19 State's approved plan under Title XIX of the Social
20 Security Act. Notwithstanding any other provision of law,
21 the Department (i) does not have a claim against the
22 estate of a deceased recipient of services under this
23 paragraph 16 and (ii) does not have a lien against any
24 homestead property or other legal or equitable real
25 property interest owned by a recipient of services under
26 this paragraph 16.
SB2437 Enrolled - 42 - LRB104 10548 KTG 20624 b
1 17. Persons who, pursuant to a waiver approved by the
2 Secretary of the U.S. Department of Health and Human
3 Services, are eligible for medical assistance under Title
4 XIX or XXI of the federal Social Security Act.
5 Notwithstanding any other provision of this Code and
6 consistent with the terms of the approved waiver, the
7 Illinois Department, may by rule:
8 (a) Limit the geographic areas in which the waiver
9 program operates.
10 (b) Determine the scope, quantity, duration, and
11 quality, and the rate and method of reimbursement, of
12 the medical services to be provided, which may differ
13 from those for other classes of persons eligible for
14 assistance under this Article.
15 (c) Restrict the persons' freedom in choice of
16 providers.
17 18. Beginning January 1, 2014, persons aged 19 or
18 older, but younger than 65, who are not otherwise eligible
19 for medical assistance under this Section 5-2, who qualify
20 for medical assistance pursuant to 42 U.S.C.
21 1396a(a)(10)(A)(i)(VIII) and applicable federal
22 regulations, and who have income at or below 133% of the
23 federal poverty level plus 5% for the applicable family
24 size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
25 applicable federal regulations. Persons eligible for
26 medical assistance under this paragraph 18 shall receive
SB2437 Enrolled - 43 - LRB104 10548 KTG 20624 b
1 coverage for the Health Benefits Service Package as that
2 term is defined in subsection (m) of Section 5-1.1 of this
3 Code. If Illinois' federal medical assistance percentage
4 (FMAP) is reduced below 90% for persons eligible for
5 medical assistance under this paragraph 18, eligibility
6 under this paragraph 18 shall cease no later than the end
7 of the third month following the month in which the
8 reduction in FMAP takes effect.
9 19. Beginning January 1, 2014, as required under 42
10 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
11 and younger than age 26 who are not otherwise eligible for
12 medical assistance under paragraphs (1) through (17) of
13 this Section who (i) were in foster care under the
14 responsibility of the State on the date of attaining age
15 18 or on the date of attaining age 21 when a court has
16 continued wardship for good cause as provided in Section
17 2-31 of the Juvenile Court Act of 1987 and (ii) received
18 medical assistance under the Illinois Title XIX State Plan
19 or waiver of such plan while in foster care.
20 20. (Blank). Beginning January 1, 2018, persons who
21 are foreign-born victims of human trafficking, torture, or
22 other serious crimes as defined in Section 2-19 of this
23 Code and their derivative family members if such persons:
24 (i) reside in Illinois; (ii) are not eligible under any of
25 the preceding paragraphs; (iii) meet the income guidelines
26 of subparagraph (a) of paragraph 2; and (iv) meet the
SB2437 Enrolled - 44 - LRB104 10548 KTG 20624 b
1 nonfinancial eligibility requirements of Sections 16-2,
2 16-3, and 16-5 of this Code. The Department may extend
3 medical assistance for persons who are foreign-born
4 victims of human trafficking, torture, or other serious
5 crimes whose medical assistance would be terminated
6 pursuant to subsection (b) of Section 16-5 if the
7 Department determines that the person, during the year of
8 initial eligibility (1) experienced a health crisis, (2)
9 has been unable, after reasonable attempts, to obtain
10 necessary information from a third party, or (3) has other
11 extenuating circumstances that prevented the person from
12 completing his or her application for status. The
13 Department may adopt any rules necessary to implement the
14 provisions of this paragraph.
15 21. Persons who are not otherwise eligible for medical
16 assistance under this Section who may qualify for medical
17 assistance pursuant to 42 U.S.C.
18 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
19 duration of any federal or State declared emergency due to
20 COVID-19. Medical assistance to persons eligible for
21 medical assistance solely pursuant to this paragraph 21
22 shall be limited to any in vitro diagnostic product (and
23 the administration of such product) described in 42 U.S.C.
24 1396d(a)(3)(B) on or after March 18, 2020, any visit
25 described in 42 U.S.C. 1396o(a)(2)(G), or any other
26 medical assistance that may be federally authorized for
SB2437 Enrolled - 45 - LRB104 10548 KTG 20624 b
1 this class of persons. The Department may also cover
2 treatment of COVID-19 for this class of persons, or any
3 similar category of uninsured individuals, to the extent
4 authorized under a federally approved 1115 Waiver or other
5 federal authority. Notwithstanding the provisions of
6 Section 1-11 of this Code, due to the nature of the
7 COVID-19 public health emergency, the Department may cover
8 and provide the medical assistance described in this
9 paragraph 21 to noncitizens who would otherwise meet the
10 eligibility requirements for the class of persons
11 described in this paragraph 21 for the duration of the
12 State emergency period.
13 In implementing the provisions of Public Act 96-20, the
14 Department is authorized to adopt only those rules necessary,
15 including emergency rules. Nothing in Public Act 96-20 permits
16 the Department to adopt rules or issue a decision that expands
17 eligibility for the FamilyCare Program to a person whose
18 income exceeds 185% of the Federal Poverty Level as determined
19 from time to time by the U.S. Department of Health and Human
20 Services, unless the Department is provided with express
21 statutory authority.
22 The eligibility of any such person for medical assistance
23 under this Article is not affected by the payment of any grant
24 under the Senior Citizens and Persons with Disabilities
25 Property Tax Relief Act or any distributions or items of
26 income described under subparagraph (X) of paragraph (2) of
SB2437 Enrolled - 46 - LRB104 10548 KTG 20624 b
1 subsection (a) of Section 203 of the Illinois Income Tax Act.
2 The Department shall by rule establish the amounts of
3 assets to be disregarded in determining eligibility for
4 medical assistance, which shall at a minimum equal the amounts
5 to be disregarded under the Federal Supplemental Security
6 Income Program. The amount of assets of a single person to be
7 disregarded shall not be less than $2,000, and the amount of
8 assets of a married couple to be disregarded shall not be less
9 than $3,000.
10 To the extent permitted under federal law, any person
11 found guilty of a second violation of Article VIIIA shall be
12 ineligible for medical assistance under this Article, as
13 provided in Section 8A-8.
14 The eligibility of any person for medical assistance under
15 this Article shall not be affected by the receipt by the person
16 of donations or benefits from fundraisers held for the person
17 in cases of serious illness, as long as neither the person nor
18 members of the person's family have actual control over the
19 donations or benefits or the disbursement of the donations or
20 benefits.
21 Notwithstanding any other provision of this Code, if the
22 United States Supreme Court holds Title II, Subtitle A,
23 Section 2001(a) of Public Law 111-148 to be unconstitutional,
24 or if a holding of Public Law 111-148 makes Medicaid
25 eligibility allowed under Section 2001(a) inoperable, the
26 State or a unit of local government shall be prohibited from
SB2437 Enrolled - 47 - LRB104 10548 KTG 20624 b
1 enrolling individuals in the Medical Assistance Program as the
2 result of federal approval of a State Medicaid waiver on or
3 after June 14, 2012 (the effective date of Public Act 97-687),
4 and any individuals enrolled in the Medical Assistance Program
5 pursuant to eligibility permitted as a result of such a State
6 Medicaid waiver shall become immediately ineligible.
7 Notwithstanding any other provision of this Code, if an
8 Act of Congress that becomes a Public Law eliminates Section
9 2001(a) of Public Law 111-148, the State or a unit of local
10 government shall be prohibited from enrolling individuals in
11 the Medical Assistance Program as the result of federal
12 approval of a State Medicaid waiver on or after June 14, 2012
13 (the effective date of Public Act 97-687), and any individuals
14 enrolled in the Medical Assistance Program pursuant to
15 eligibility permitted as a result of such a State Medicaid
16 waiver shall become immediately ineligible.
17 Effective October 1, 2013, the determination of
18 eligibility of persons who qualify under paragraphs 5, 6, 8,
19 15, 17, and 18 of this Section shall comply with the
20 requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
21 regulations.
22 The Department of Healthcare and Family Services, the
23 Department of Human Services, and the Illinois health
24 insurance marketplace shall work cooperatively to assist
25 persons who would otherwise lose health benefits as a result
26 of changes made under Public Act 98-104 to transition to other
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1 health insurance coverage.
2 (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20;
3 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff.
4 10-8-21; 102-813, eff. 5-13-22.)
5 ARTICLE 15.
6 Section 15-5. The Illinois Public Aid Code is amended by
7 changing Section 5-5.09a as follows:
8 (305 ILCS 5/5-5.09a new)
9 Sec. 5-5.09a. Screening for tardive dyskinesia.
10 (a) Notwithstanding any other provisions of law, the
11 Department of Healthcare and Family Services shall develop, in
12 collaboration with the Department of Human Services and the
13 Department of Public Health, recommended screening guidelines
14 for tardive dyskinesia for providers serving patients
15 prescribed antipsychotic medications under the medical
16 assistance program in State-operated residential facilities
17 and community-based settings.
18 (b) The recommended screening guidelines shall be based on
19 current, nationally accepted, evidence-based recommendations
20 for the assessment and treatment of tardive dyskinesia, and
21 shall include structured assessment tools, which can be both
22 quantitative and qualitative.
23 (c) The Department of Healthcare and Family Services and
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1 the Department of Human Services, in collaboration with the
2 Department of Public Health, shall develop communication
3 strategies and educational materials to be offered to health
4 care providers regarding tardive dyskinesia, the recommended
5 screening guidelines, and any subsequent revisions. In
6 developing the information to be disseminated under this
7 Section, the Departments of Healthcare and Family Services,
8 Human Services, and Public Health shall consult with a
9 statewide association representing physicians licensed to
10 practice medicine in all its branches and a statewide
11 association representing psychiatrists.
12 ARTICLE 20.
13 Section 20-5. The Illinois Public Aid Code is amended by
14 changing Section 5-5.12f as follows:
15 (305 ILCS 5/5-5.12f)
16 Sec. 5-5.12f. Prescription drugs for mental illness; no
17 utilization or prior approval mandates.
18 (a) Notwithstanding any other provision of this Code to
19 the contrary, except as otherwise provided in subsection (b),
20 for the purpose of removing barriers to the timely treatment
21 of serious mental illnesses, prior authorization mandates and
22 utilization management controls shall not be imposed under the
23 fee-for-service and managed care medical assistance programs
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1 on any FDA-approved prescription drug that is recognized by a
2 generally accepted standard medical reference as effective in
3 the treatment of conditions specified in the most recent
4 Diagnostic and Statistical Manual of Mental Disorders
5 published by the American Psychiatric Association if a
6 preferred or non-preferred drug is prescribed to an adult
7 patient to treat serious mental illness and one of the
8 following applies:
9 (1) the patient has changed providers, including, but
10 not limited to, a change from an inpatient to an
11 outpatient provider, and is stable on the drug that has
12 been previously prescribed, and received prior
13 authorization, if required;
14 (2) the patient has changed Medical assistance program
15 or managed care plan insurance coverage and is stable on
16 the drug that has been previously prescribed and received
17 prior authorization under the previous source of coverage;
18 or
19 (3) subject to federal law on maximum dosage limits
20 and safety edits adopted by the Department's Drug and
21 Therapeutics Board, including those safety edits and
22 limits needed to comply with federal requirements
23 contained in 42 CFR 456.703, the patient has previously
24 been prescribed and obtained prior authorization for the
25 drug and the prescription modifies the dosage, dosage
26 frequency, or both, of the drug as part of the same
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1 treatment for which the drug was previously prescribed.
2 (b) The following safety edits shall be permitted for
3 prescription drugs covered under this Section:
4 (1) clinically appropriate drug utilization review
5 (DUR) edits, including, but not limited to, drug-to-drug,
6 drug-age, and drug-dose;
7 (2) generic drug substitution if a generic drug is
8 available for the prescribed medication in the same dosage
9 and formulation; and
10 (3) any utilization management control that is
11 necessary for the Department to comply with any current
12 consent decrees or federal waivers.
13 (c) As used in this Section, "serious mental illness"
14 means any one or more of the following diagnoses and
15 International Classification of Diseases, Tenth Revision,
16 Clinical Modification (ICD-10-CM) codes listed by the
17 Department of Human Services' Division of Mental Health, as
18 amended, on its official website:
19 (1) Delusional Disorder (F22)
20 (2) Brief Psychotic Disorder (F23)
21 (3) Schizophreniform Disorder (F20.81)
22 (4) Schizophrenia (F20.9)
23 (5) Schizoaffective Disorder (F25.x)
24 (6) Catatonia Associated with Another Mental Disorder
25 (Catatonia Specifier) (F06.1)
26 (7) Other Specified Schizophrenia Spectrum and Other
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1 Psychotic Disorder (F28)
2 (8) Unspecified Schizophrenia Spectrum and Other
3 Psychotic Disorder (F29)
4 (9) Bipolar I Disorder (F31.xx)
5 (10) Bipolar II Disorder (F31.81)
6 (11) Cyclothymic Disorder (F34.0)
7 (12) Unspecified Bipolar and Related Disorder (F31.9)
8 (13) Disruptive Mood Dysregulation Disorder (F34.8)
9 (14) Major Depressive Disorder Single episode (F32.xx)
10 (15) Major Depressive Disorder, Recurrent episode
11 (F33.xx)
12 (16) Obsessive-Compulsive Disorder (F42)
13 (17) Posttraumatic Stress Disorder (F43.10)
14 (18) Anorexia Nervosa (F50.0x)
15 (19) Bulimia Nervosa (F50.2)
16 (20) Postpartum Depression (F53.0)
17 (21) Puerperal Psychosis (F53.1)
18 (22) Factitious Disorder Imposed on Another (F68.A)
19 (d) Notwithstanding any other provision of law, nothing in
20 this Section shall not be construed to conflict with Section
21 1927(a)(1) and (b)(1)(A) of the federal Social Security Act
22 and any implementing regulations and agreements.
23 (e) The Department shall publish a report semi-annually on
24 its website on compliance with the conditions of this Section
25 by the fee-for-service program and managed care organizations
26 beginning with dates of service on and after July 1, 2025.
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1 These reports shall be due 12 months after the end of the
2 period to be reported. These reports shall include:
3 (1) The number of clinically denied prescriptions
4 summarized by each of the allowed categories specified in
5 subsection (b). This paragraph shall include the number of
6 prior authorization denials.
7 (2) The number of clinically denied prescriptions as
8 summarized by each of the nonallowed categories specified
9 in subsection (a), categorized by denial reason.
10 (3) The number of prior authorizations of
11 prescriptions contrary to the prohibition described in
12 subsection (a).
13 (4) The number of complaints filed concerning denials
14 for prescriptions, which meet the conditions specified in
15 subsection (a).
16 (5) The number of approved and paid prescriptions
17 described in subsection (a) and the potential net cost to
18 the State.
19 (6) The number of persons enrolled in the medical
20 assistance program using emergency room services based on
21 categories specified in subsection (c) as the primary
22 diagnosis for the emergency room visit.
23 (7) The number of persons admitted into a hospital and
24 the number of hospital readmissions, based on categories
25 specified in subsection (c) as the primary diagnosis for
26 the hospital admission or readmission.
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1 As used in this Section, "net cost" means the difference
2 in total ingredient cost due to changes in product mix plus
3 total loss in aggregate rebate revenue based on product mix
4 realized in Fiscal Year 2025. Nothing in this Section shall
5 require the Department to disclose information that is exempt
6 from disclosure under paragraph (g) of subsection (1) of
7 Section 7 of the Freedom of Information Act.
8 For purposes of this Section, a hospital readmission
9 occurs when a patient is discharged from a hospital and then
10 admitted into the same or another hospital within 30 days of
11 discharge for the same primary diagnosis.
12 (Source: P.A. 103-593, eff. 6-7-24.)
13 ARTICLE 30.
14 Section 30-5. The Illinois Public Aid Code is amended by
15 changing Section 5-2b as follows:
16 (305 ILCS 5/5-2b)
17 Sec. 5-2b. Medically fragile and technology dependent
18 children eligibility and program; provider reimbursement
19 rates.
20 (a) Notwithstanding any other provision of law except as
21 provided in Section 5-30a, on and after September 1, 2012,
22 subject to federal approval, medical assistance under this
23 Article shall be available to children who qualify as persons
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1 with a disability, as defined under the federal Supplemental
2 Security Income program and who are medically fragile and
3 technology dependent. The program shall allow eligible
4 children to receive the medical assistance provided under this
5 Article in the community and must maximize, to the fullest
6 extent permissible under federal law, federal reimbursement
7 and family cost-sharing, including co-pays, premiums, or any
8 other family contributions, except that the Department shall
9 be permitted to incentivize the utilization of selected
10 services through the use of cost-sharing adjustments. The
11 Department shall establish the policies, procedures,
12 standards, services, and criteria for this program by rule.
13 (b) Notwithstanding any other provision of this Code,
14 subject to federal approval, on and after January 1, 2024, the
15 reimbursement rates for nursing paid through Nursing and
16 Personal Care Services for non-waiver customers and to
17 providers of private duty nursing services for children
18 eligible for medical assistance under this Section shall be
19 20% higher than the reimbursement rates in effect for nursing
20 services on December 31, 2023.
21 (c) Notwithstanding any other provision of this Code,
22 subject to federal approval, on and after January 1, 2025, the
23 reimbursement rates for nursing paid through Nursing and
24 Personal Care Services for non-waiver customers and to
25 providers of private duty nursing services for children
26 eligible for medical assistance under this Section shall be 7%
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1 higher than the reimbursement rates in effect for nursing
2 services on December 31, 2024.
3 (d) The Department shall conduct an evaluation to study
4 the program, including service provision and design, waiver
5 operations, and methodologies and policies for setting rates
6 and reimbursements for services and supports that are provided
7 to (i) individuals under the age of 21 who are approved by the
8 Department for in-home shift nursing services and (ii)
9 individuals over the age of 21 who are receiving in-home shift
10 nursing services under the Home and Community-Based Services
11 Waiver for Medically Fragile and Technology Dependent
12 Children, including, but not limited to, in-home shift nursing
13 services and related home and community-based services and
14 supports, made to nursing agencies for such services. As
15 needed, the Department shall consult with Department-enrolled
16 providers of in-home shift nursing services to ensure accurate
17 information is considered in the evaluation, and the
18 Department may, to the extent it deems necessary and
19 appropriate, contract with an outside entity to assist or
20 provide further analysis in the support of the evaluation.
21 (Source: P.A. 103-102, eff. 1-1-24; 103-593, eff. 6-7-24.)
22 ARTICLE 35.
23 Section 35-5. The Illinois Public Aid Code is amended by
24 adding Section 5-65 as follows:
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1 (305 ILCS 5/5-65 new)
2 Sec. 5-65. Reimbursement rates for long-term
3 electrocardiogram monitoring.
4 (a) As used in this Section, "long-term ambulatory
5 electrocardiogram monitoring services" means the provision of
6 external cardiac patch monitoring devices to patients to wear
7 for 48 hours or greater and the interpretation of data
8 gathered by such devices to detect heart arrhythmias that can
9 lead to stroke, cardiac arrest, or other comorbidities or
10 medical complications if not correctly diagnosed.
11 (b) Subject to federal approval, for dates of service on
12 and after January 1, 2026, the Department shall reimburse
13 diagnostic testing facilities that provide long-term
14 ambulatory electrocardiogram monitoring services at a rate not
15 less than 80% of the Medicare Physician Fee Schedule rate in
16 effect for such services on the effective date of this
17 amendatory Act of the 104th General Assembly.
18 ARTICLE 40.
19 Section 40-5. The Illinois Public Aid Code is amended by
20 changing Section 5-5 as follows:
21 (305 ILCS 5/5-5)
22 (Text of Section before amendment by P.A. 103-808)
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1 Sec. 5-5. Medical services. The Illinois Department, by
2 rule, shall determine the quantity and quality of and the rate
3 of reimbursement for the medical assistance for which payment
4 will be authorized, and the medical services to be provided,
5 which may include all or part of the following: (1) inpatient
6 hospital services; (2) outpatient hospital services; (3) other
7 laboratory and X-ray services; (4) skilled nursing home
8 services; (5) physicians' services whether furnished in the
9 office, the patient's home, a hospital, a skilled nursing
10 home, or elsewhere; (6) medical care, or any other type of
11 remedial care furnished by licensed practitioners; (7) home
12 health care services; (8) private duty nursing service; (9)
13 clinic services; (10) dental services, including prevention
14 and treatment of periodontal disease and dental caries disease
15 for pregnant individuals, provided by an individual licensed
16 to practice dentistry or dental surgery; for purposes of this
17 item (10), "dental services" means diagnostic, preventive, or
18 corrective procedures provided by or under the supervision of
19 a dentist in the practice of his or her profession; (11)
20 physical therapy and related services; (12) prescribed drugs,
21 dentures, and prosthetic devices; and eyeglasses prescribed by
22 a physician skilled in the diseases of the eye, or by an
23 optometrist, whichever the person may select; (13) other
24 diagnostic, screening, preventive, and rehabilitative
25 services, including to ensure that the individual's need for
26 intervention or treatment of mental disorders or substance use
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1 disorders or co-occurring mental health and substance use
2 disorders is determined using a uniform screening, assessment,
3 and evaluation process inclusive of criteria, for children and
4 adults; for purposes of this item (13), a uniform screening,
5 assessment, and evaluation process refers to a process that
6 includes an appropriate evaluation and, as warranted, a
7 referral; "uniform" does not mean the use of a singular
8 instrument, tool, or process that all must utilize; (14)
9 transportation and such other expenses as may be necessary;
10 (15) medical treatment of sexual assault survivors, as defined
11 in Section 1a of the Sexual Assault Survivors Emergency
12 Treatment Act, for injuries sustained as a result of the
13 sexual assault, including examinations and laboratory tests to
14 discover evidence which may be used in criminal proceedings
15 arising from the sexual assault; (16) the diagnosis and
16 treatment of sickle cell anemia; (16.5) services performed by
17 a chiropractic physician licensed under the Medical Practice
18 Act of 1987 and acting within the scope of his or her license,
19 including, but not limited to, chiropractic manipulative
20 treatment; and (17) any other medical care, and any other type
21 of remedial care recognized under the laws of this State. The
22 term "any other type of remedial care" shall include nursing
23 care and nursing home service for persons who rely on
24 treatment by spiritual means alone through prayer for healing.
25 Notwithstanding any other provision of this Section, a
26 comprehensive tobacco use cessation program that includes
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1 purchasing prescription drugs or prescription medical devices
2 approved by the Food and Drug Administration shall be covered
3 under the medical assistance program under this Article for
4 persons who are otherwise eligible for assistance under this
5 Article.
6 Notwithstanding any other provision of this Code,
7 reproductive health care that is otherwise legal in Illinois
8 shall be covered under the medical assistance program for
9 persons who are otherwise eligible for medical assistance
10 under this Article.
11 Notwithstanding any other provision of this Section, all
12 tobacco cessation medications approved by the United States
13 Food and Drug Administration and all individual and group
14 tobacco cessation counseling services and telephone-based
15 counseling services and tobacco cessation medications provided
16 through the Illinois Tobacco Quitline shall be covered under
17 the medical assistance program for persons who are otherwise
18 eligible for assistance under this Article. The Department
19 shall comply with all federal requirements necessary to obtain
20 federal financial participation, as specified in 42 CFR
21 433.15(b)(7), for telephone-based counseling services provided
22 through the Illinois Tobacco Quitline, including, but not
23 limited to: (i) entering into a memorandum of understanding or
24 interagency agreement with the Department of Public Health, as
25 administrator of the Illinois Tobacco Quitline; and (ii)
26 developing a cost allocation plan for Medicaid-allowable
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1 Illinois Tobacco Quitline services in accordance with 45 CFR
2 95.507. The Department shall submit the memorandum of
3 understanding or interagency agreement, the cost allocation
4 plan, and all other necessary documentation to the Centers for
5 Medicare and Medicaid Services for review and approval.
6 Coverage under this paragraph shall be contingent upon federal
7 approval.
8 Notwithstanding any other provision of this Code, the
9 Illinois Department may not require, as a condition of payment
10 for any laboratory test authorized under this Article, that a
11 physician's handwritten signature appear on the laboratory
12 test order form. The Illinois Department may, however, impose
13 other appropriate requirements regarding laboratory test order
14 documentation.
15 Upon receipt of federal approval of an amendment to the
16 Illinois Title XIX State Plan for this purpose, the Department
17 shall authorize the Chicago Public Schools (CPS) to procure a
18 vendor or vendors to manufacture eyeglasses for individuals
19 enrolled in a school within the CPS system. CPS shall ensure
20 that its vendor or vendors are enrolled as providers in the
21 medical assistance program and in any capitated Medicaid
22 managed care entity (MCE) serving individuals enrolled in a
23 school within the CPS system. Under any contract procured
24 under this provision, the vendor or vendors must serve only
25 individuals enrolled in a school within the CPS system. Claims
26 for services provided by CPS's vendor or vendors to recipients
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1 of benefits in the medical assistance program under this Code,
2 the Children's Health Insurance Program, or the Covering ALL
3 KIDS Health Insurance Program shall be submitted to the
4 Department or the MCE in which the individual is enrolled for
5 payment and shall be reimbursed at the Department's or the
6 MCE's established rates or rate methodologies for eyeglasses.
7 On and after July 1, 2012, the Department of Healthcare
8 and Family Services may provide the following services to
9 persons eligible for assistance under this Article who are
10 participating in education, training or employment programs
11 operated by the Department of Human Services as successor to
12 the Department of Public Aid:
13 (1) dental services provided by or under the
14 supervision of a dentist; and
15 (2) eyeglasses prescribed by a physician skilled in
16 the diseases of the eye, or by an optometrist, whichever
17 the person may select.
18 On and after July 1, 2018, the Department of Healthcare
19 and Family Services shall provide dental services to any adult
20 who is otherwise eligible for assistance under the medical
21 assistance program. As used in this paragraph, "dental
22 services" means diagnostic, preventative, restorative, or
23 corrective procedures, including procedures and services for
24 the prevention and treatment of periodontal disease and dental
25 caries disease, provided by an individual who is licensed to
26 practice dentistry or dental surgery or who is under the
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1 supervision of a dentist in the practice of his or her
2 profession.
3 On and after July 1, 2018, targeted dental services, as
4 set forth in Exhibit D of the Consent Decree entered by the
5 United States District Court for the Northern District of
6 Illinois, Eastern Division, in the matter of Memisovski v.
7 Maram, Case No. 92 C 1982, that are provided to adults under
8 the medical assistance program shall be established at no less
9 than the rates set forth in the "New Rate" column in Exhibit D
10 of the Consent Decree for targeted dental services that are
11 provided to persons under the age of 18 under the medical
12 assistance program.
13 Subject to federal approval, on and after January 1, 2025,
14 the rates paid for sedation evaluation and the provision of
15 deep sedation and intravenous sedation for the purpose of
16 dental services shall be increased by 33% above the rates in
17 effect on December 31, 2024. The rates paid for nitrous oxide
18 sedation shall not be impacted by this paragraph and shall
19 remain the same as the rates in effect on December 31, 2024.
20 Notwithstanding any other provision of this Code and
21 subject to federal approval, the Department may adopt rules to
22 allow a dentist who is volunteering his or her service at no
23 cost to render dental services through an enrolled
24 not-for-profit health clinic without the dentist personally
25 enrolling as a participating provider in the medical
26 assistance program. A not-for-profit health clinic shall
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1 include a public health clinic or Federally Qualified Health
2 Center or other enrolled provider, as determined by the
3 Department, through which dental services covered under this
4 Section are performed. The Department shall establish a
5 process for payment of claims for reimbursement for covered
6 dental services rendered under this provision.
7 Subject to appropriation and to federal approval, the
8 Department shall file administrative rules updating the
9 Handicapping Labio-Lingual Deviation orthodontic scoring tool
10 by January 1, 2025, or as soon as practicable.
11 On and after January 1, 2022, the Department of Healthcare
12 and Family Services shall administer and regulate a
13 school-based dental program that allows for the out-of-office
14 delivery of preventative dental services in a school setting
15 to children under 19 years of age. The Department shall
16 establish, by rule, guidelines for participation by providers
17 and set requirements for follow-up referral care based on the
18 requirements established in the Dental Office Reference Manual
19 published by the Department that establishes the requirements
20 for dentists participating in the All Kids Dental School
21 Program. Every effort shall be made by the Department when
22 developing the program requirements to consider the different
23 geographic differences of both urban and rural areas of the
24 State for initial treatment and necessary follow-up care. No
25 provider shall be charged a fee by any unit of local government
26 to participate in the school-based dental program administered
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1 by the Department. Nothing in this paragraph shall be
2 construed to limit or preempt a home rule unit's or school
3 district's authority to establish, change, or administer a
4 school-based dental program in addition to, or independent of,
5 the school-based dental program administered by the
6 Department.
7 The Illinois Department, by rule, may distinguish and
8 classify the medical services to be provided only in
9 accordance with the classes of persons designated in Section
10 5-2.
11 The Department of Healthcare and Family Services must
12 provide coverage and reimbursement for amino acid-based
13 elemental formulas, regardless of delivery method, for the
14 diagnosis and treatment of (i) eosinophilic disorders and (ii)
15 short bowel syndrome when the prescribing physician has issued
16 a written order stating that the amino acid-based elemental
17 formula is medically necessary.
18 The Illinois Department shall authorize the provision of,
19 and shall authorize payment for, screening by low-dose
20 mammography for the presence of occult breast cancer for
21 individuals 35 years of age or older who are eligible for
22 medical assistance under this Article, as follows:
23 (A) A baseline mammogram for individuals 35 to 39
24 years of age.
25 (B) An annual mammogram for individuals 40 years of
26 age or older.
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1 (C) A mammogram at the age and intervals considered
2 medically necessary by the individual's health care
3 provider for individuals under 40 years of age and having
4 a family history of breast cancer, prior personal history
5 of breast cancer, positive genetic testing, or other risk
6 factors.
7 (D) A comprehensive ultrasound screening and MRI of an
8 entire breast or breasts if a mammogram demonstrates
9 heterogeneous or dense breast tissue or when medically
10 necessary as determined by a physician licensed to
11 practice medicine in all of its branches.
12 (E) A screening MRI when medically necessary, as
13 determined by a physician licensed to practice medicine in
14 all of its branches.
15 (F) A diagnostic mammogram when medically necessary,
16 as determined by a physician licensed to practice medicine
17 in all its branches, advanced practice registered nurse,
18 or physician assistant.
19 The Department shall not impose a deductible, coinsurance,
20 copayment, or any other cost-sharing requirement on the
21 coverage provided under this paragraph; except that this
22 sentence does not apply to coverage of diagnostic mammograms
23 to the extent such coverage would disqualify a high-deductible
24 health plan from eligibility for a health savings account
25 pursuant to Section 223 of the Internal Revenue Code (26
26 U.S.C. 223).
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1 All screenings shall include a physical breast exam,
2 instruction on self-examination and information regarding the
3 frequency of self-examination and its value as a preventative
4 tool.
5 For purposes of this Section:
6 "Diagnostic mammogram" means a mammogram obtained using
7 diagnostic mammography.
8 "Diagnostic mammography" means a method of screening that
9 is designed to evaluate an abnormality in a breast, including
10 an abnormality seen or suspected on a screening mammogram or a
11 subjective or objective abnormality otherwise detected in the
12 breast.
13 "Low-dose mammography" means the x-ray examination of the
14 breast using equipment dedicated specifically for mammography,
15 including the x-ray tube, filter, compression device, and
16 image receptor, with an average radiation exposure delivery of
17 less than one rad per breast for 2 views of an average size
18 breast. The term also includes digital mammography and
19 includes breast tomosynthesis.
20 "Breast tomosynthesis" means a radiologic procedure that
21 involves the acquisition of projection images over the
22 stationary breast to produce cross-sectional digital
23 three-dimensional images of the breast.
24 If, at any time, the Secretary of the United States
25 Department of Health and Human Services, or its successor
26 agency, promulgates rules or regulations to be published in
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1 the Federal Register or publishes a comment in the Federal
2 Register or issues an opinion, guidance, or other action that
3 would require the State, pursuant to any provision of the
4 Patient Protection and Affordable Care Act (Public Law
5 111-148), including, but not limited to, 42 U.S.C.
6 18031(d)(3)(B) or any successor provision, to defray the cost
7 of any coverage for breast tomosynthesis outlined in this
8 paragraph, then the requirement that an insurer cover breast
9 tomosynthesis is inoperative other than any such coverage
10 authorized under Section 1902 of the Social Security Act, 42
11 U.S.C. 1396a, and the State shall not assume any obligation
12 for the cost of coverage for breast tomosynthesis set forth in
13 this paragraph.
14 On and after January 1, 2016, the Department shall ensure
15 that all networks of care for adult clients of the Department
16 include access to at least one breast imaging Center of
17 Imaging Excellence as certified by the American College of
18 Radiology.
19 On and after January 1, 2012, providers participating in a
20 quality improvement program approved by the Department shall
21 be reimbursed for screening and diagnostic mammography at the
22 same rate as the Medicare program's rates, including the
23 increased reimbursement for digital mammography and, after
24 January 1, 2023 (the effective date of Public Act 102-1018),
25 breast tomosynthesis.
26 The Department shall convene an expert panel including
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1 representatives of hospitals, free-standing mammography
2 facilities, and doctors, including radiologists, to establish
3 quality standards for mammography.
4 On and after January 1, 2017, providers participating in a
5 breast cancer treatment quality improvement program approved
6 by the Department shall be reimbursed for breast cancer
7 treatment at a rate that is no lower than 95% of the Medicare
8 program's rates for the data elements included in the breast
9 cancer treatment quality program.
10 The Department shall convene an expert panel, including
11 representatives of hospitals, free-standing breast cancer
12 treatment centers, breast cancer quality organizations, and
13 doctors, including breast surgeons, reconstructive breast
14 surgeons, oncologists, and primary care providers to establish
15 quality standards for breast cancer treatment.
16 Subject to federal approval, the Department shall
17 establish a rate methodology for mammography at federally
18 qualified health centers and other encounter-rate clinics.
19 These clinics or centers may also collaborate with other
20 hospital-based mammography facilities. By January 1, 2016, the
21 Department shall report to the General Assembly on the status
22 of the provision set forth in this paragraph.
23 The Department shall establish a methodology to remind
24 individuals who are age-appropriate for screening mammography,
25 but who have not received a mammogram within the previous 18
26 months, of the importance and benefit of screening
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1 mammography. The Department shall work with experts in breast
2 cancer outreach and patient navigation to optimize these
3 reminders and shall establish a methodology for evaluating
4 their effectiveness and modifying the methodology based on the
5 evaluation.
6 The Department shall establish a performance goal for
7 primary care providers with respect to their female patients
8 over age 40 receiving an annual mammogram. This performance
9 goal shall be used to provide additional reimbursement in the
10 form of a quality performance bonus to primary care providers
11 who meet that goal.
12 The Department shall devise a means of case-managing or
13 patient navigation for beneficiaries diagnosed with breast
14 cancer. This program shall initially operate as a pilot
15 program in areas of the State with the highest incidence of
16 mortality related to breast cancer. At least one pilot program
17 site shall be in the metropolitan Chicago area and at least one
18 site shall be outside the metropolitan Chicago area. On or
19 after July 1, 2016, the pilot program shall be expanded to
20 include one site in western Illinois, one site in southern
21 Illinois, one site in central Illinois, and 4 sites within
22 metropolitan Chicago. An evaluation of the pilot program shall
23 be carried out measuring health outcomes and cost of care for
24 those served by the pilot program compared to similarly
25 situated patients who are not served by the pilot program.
26 The Department shall require all networks of care to
SB2437 Enrolled - 71 - LRB104 10548 KTG 20624 b
1 develop a means either internally or by contract with experts
2 in navigation and community outreach to navigate cancer
3 patients to comprehensive care in a timely fashion. The
4 Department shall require all networks of care to include
5 access for patients diagnosed with cancer to at least one
6 academic commission on cancer-accredited cancer program as an
7 in-network covered benefit.
8 The Department shall provide coverage and reimbursement
9 for a human papillomavirus (HPV) vaccine that is approved for
10 marketing by the federal Food and Drug Administration for all
11 persons between the ages of 9 and 45. Subject to federal
12 approval, the Department shall provide coverage and
13 reimbursement for a human papillomavirus (HPV) vaccine for
14 persons of the age of 46 and above who have been diagnosed with
15 cervical dysplasia with a high risk of recurrence or
16 progression. The Department shall disallow any
17 preauthorization requirements for the administration of the
18 human papillomavirus (HPV) vaccine.
19 On or after July 1, 2022, individuals who are otherwise
20 eligible for medical assistance under this Article shall
21 receive coverage for perinatal depression screenings for the
22 12-month period beginning on the last day of their pregnancy.
23 Medical assistance coverage under this paragraph shall be
24 conditioned on the use of a screening instrument approved by
25 the Department.
26 Any medical or health care provider shall immediately
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1 recommend, to any pregnant individual who is being provided
2 prenatal services and is suspected of having a substance use
3 disorder as defined in the Substance Use Disorder Act,
4 referral to a local substance use disorder treatment program
5 licensed by the Department of Human Services or to a licensed
6 hospital which provides substance abuse treatment services.
7 The Department of Healthcare and Family Services shall assure
8 coverage for the cost of treatment of the drug abuse or
9 addiction for pregnant recipients in accordance with the
10 Illinois Medicaid Program in conjunction with the Department
11 of Human Services.
12 All medical providers providing medical assistance to
13 pregnant individuals under this Code shall receive information
14 from the Department on the availability of services under any
15 program providing case management services for addicted
16 individuals, including information on appropriate referrals
17 for other social services that may be needed by addicted
18 individuals in addition to treatment for addiction.
19 The Illinois Department, in cooperation with the
20 Departments of Human Services (as successor to the Department
21 of Alcoholism and Substance Abuse) and Public Health, through
22 a public awareness campaign, may provide information
23 concerning treatment for alcoholism and drug abuse and
24 addiction, prenatal health care, and other pertinent programs
25 directed at reducing the number of drug-affected infants born
26 to recipients of medical assistance.
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1 Neither the Department of Healthcare and Family Services
2 nor the Department of Human Services shall sanction the
3 recipient solely on the basis of the recipient's substance
4 abuse.
5 The Illinois Department shall establish such regulations
6 governing the dispensing of health services under this Article
7 as it shall deem appropriate. The Department should seek the
8 advice of formal professional advisory committees appointed by
9 the Director of the Illinois Department for the purpose of
10 providing regular advice on policy and administrative matters,
11 information dissemination and educational activities for
12 medical and health care providers, and consistency in
13 procedures to the Illinois Department.
14 The Illinois Department may develop and contract with
15 Partnerships of medical providers to arrange medical services
16 for persons eligible under Section 5-2 of this Code.
17 Implementation of this Section may be by demonstration
18 projects in certain geographic areas. The Partnership shall be
19 represented by a sponsor organization. The Department, by
20 rule, shall develop qualifications for sponsors of
21 Partnerships. Nothing in this Section shall be construed to
22 require that the sponsor organization be a medical
23 organization.
24 The sponsor must negotiate formal written contracts with
25 medical providers for physician services, inpatient and
26 outpatient hospital care, home health services, treatment for
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1 alcoholism and substance abuse, and other services determined
2 necessary by the Illinois Department by rule for delivery by
3 Partnerships. Physician services must include prenatal and
4 obstetrical care. The Illinois Department shall reimburse
5 medical services delivered by Partnership providers to clients
6 in target areas according to provisions of this Article and
7 the Illinois Health Finance Reform Act, except that:
8 (1) Physicians participating in a Partnership and
9 providing certain services, which shall be determined by
10 the Illinois Department, to persons in areas covered by
11 the Partnership may receive an additional surcharge for
12 such services.
13 (2) The Department may elect to consider and negotiate
14 financial incentives to encourage the development of
15 Partnerships and the efficient delivery of medical care.
16 (3) Persons receiving medical services through
17 Partnerships may receive medical and case management
18 services above the level usually offered through the
19 medical assistance program.
20 Medical providers shall be required to meet certain
21 qualifications to participate in Partnerships to ensure the
22 delivery of high quality medical services. These
23 qualifications shall be determined by rule of the Illinois
24 Department and may be higher than qualifications for
25 participation in the medical assistance program. Partnership
26 sponsors may prescribe reasonable additional qualifications
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1 for participation by medical providers, only with the prior
2 written approval of the Illinois Department.
3 Nothing in this Section shall limit the free choice of
4 practitioners, hospitals, and other providers of medical
5 services by clients. In order to ensure patient freedom of
6 choice, the Illinois Department shall immediately promulgate
7 all rules and take all other necessary actions so that
8 provided services may be accessed from therapeutically
9 certified optometrists to the full extent of the Illinois
10 Optometric Practice Act of 1987 without discriminating between
11 service providers.
12 The Department shall apply for a waiver from the United
13 States Health Care Financing Administration to allow for the
14 implementation of Partnerships under this Section.
15 The Illinois Department shall require health care
16 providers to maintain records that document the medical care
17 and services provided to recipients of Medical Assistance
18 under this Article. Such records must be retained for a period
19 of not less than 6 years from the date of service or as
20 provided by applicable State law, whichever period is longer,
21 except that if an audit is initiated within the required
22 retention period then the records must be retained until the
23 audit is completed and every exception is resolved. The
24 Illinois Department shall require health care providers to
25 make available, when authorized by the patient, in writing,
26 the medical records in a timely fashion to other health care
SB2437 Enrolled - 76 - LRB104 10548 KTG 20624 b
1 providers who are treating or serving persons eligible for
2 Medical Assistance under this Article. All dispensers of
3 medical services shall be required to maintain and retain
4 business and professional records sufficient to fully and
5 accurately document the nature, scope, details and receipt of
6 the health care provided to persons eligible for medical
7 assistance under this Code, in accordance with regulations
8 promulgated by the Illinois Department. The rules and
9 regulations shall require that proof of the receipt of
10 prescription drugs, dentures, prosthetic devices and
11 eyeglasses by eligible persons under this Section accompany
12 each claim for reimbursement submitted by the dispenser of
13 such medical services. No such claims for reimbursement shall
14 be approved for payment by the Illinois Department without
15 such proof of receipt, unless the Illinois Department shall
16 have put into effect and shall be operating a system of
17 post-payment audit and review which shall, on a sampling
18 basis, be deemed adequate by the Illinois Department to assure
19 that such drugs, dentures, prosthetic devices and eyeglasses
20 for which payment is being made are actually being received by
21 eligible recipients. Within 90 days after September 16, 1984
22 (the effective date of Public Act 83-1439), the Illinois
23 Department shall establish a current list of acquisition costs
24 for all prosthetic devices and any other items recognized as
25 medical equipment and supplies reimbursable under this Article
26 and shall update such list on a quarterly basis, except that
SB2437 Enrolled - 77 - LRB104 10548 KTG 20624 b
1 the acquisition costs of all prescription drugs shall be
2 updated no less frequently than every 30 days as required by
3 Section 5-5.12.
4 Notwithstanding any other law to the contrary, the
5 Illinois Department shall, within 365 days after July 22, 2013
6 (the effective date of Public Act 98-104), establish
7 procedures to permit skilled care facilities licensed under
8 the Nursing Home Care Act to submit monthly billing claims for
9 reimbursement purposes. Following development of these
10 procedures, the Department shall, by July 1, 2016, test the
11 viability of the new system and implement any necessary
12 operational or structural changes to its information
13 technology platforms in order to allow for the direct
14 acceptance and payment of nursing home claims.
15 Notwithstanding any other law to the contrary, the
16 Illinois Department shall, within 365 days after August 15,
17 2014 (the effective date of Public Act 98-963), establish
18 procedures to permit ID/DD facilities licensed under the ID/DD
19 Community Care Act and MC/DD facilities licensed under the
20 MC/DD Act to submit monthly billing claims for reimbursement
21 purposes. Following development of these procedures, the
22 Department shall have an additional 365 days to test the
23 viability of the new system and to ensure that any necessary
24 operational or structural changes to its information
25 technology platforms are implemented.
26 The Illinois Department shall require all dispensers of
SB2437 Enrolled - 78 - LRB104 10548 KTG 20624 b
1 medical services, other than an individual practitioner or
2 group of practitioners, desiring to participate in the Medical
3 Assistance program established under this Article to disclose
4 all financial, beneficial, ownership, equity, surety or other
5 interests in any and all firms, corporations, partnerships,
6 associations, business enterprises, joint ventures, agencies,
7 institutions or other legal entities providing any form of
8 health care services in this State under this Article.
9 The Illinois Department may require that all dispensers of
10 medical services desiring to participate in the medical
11 assistance program established under this Article disclose,
12 under such terms and conditions as the Illinois Department may
13 by rule establish, all inquiries from clients and attorneys
14 regarding medical bills paid by the Illinois Department, which
15 inquiries could indicate potential existence of claims or
16 liens for the Illinois Department.
17 Enrollment of a vendor shall be subject to a provisional
18 period and shall be conditional for one year. During the
19 period of conditional enrollment, the Department may terminate
20 the vendor's eligibility to participate in, or may disenroll
21 the vendor from, the medical assistance program without cause.
22 Unless otherwise specified, such termination of eligibility or
23 disenrollment is not subject to the Department's hearing
24 process. However, a disenrolled vendor may reapply without
25 penalty.
26 The Department has the discretion to limit the conditional
SB2437 Enrolled - 79 - LRB104 10548 KTG 20624 b
1 enrollment period for vendors based upon the category of risk
2 of the vendor.
3 Prior to enrollment and during the conditional enrollment
4 period in the medical assistance program, all vendors shall be
5 subject to enhanced oversight, screening, and review based on
6 the risk of fraud, waste, and abuse that is posed by the
7 category of risk of the vendor. The Illinois Department shall
8 establish the procedures for oversight, screening, and review,
9 which may include, but need not be limited to: criminal and
10 financial background checks; fingerprinting; license,
11 certification, and authorization verifications; unscheduled or
12 unannounced site visits; database checks; prepayment audit
13 reviews; audits; payment caps; payment suspensions; and other
14 screening as required by federal or State law.
15 The Department shall define or specify the following: (i)
16 by provider notice, the "category of risk of the vendor" for
17 each type of vendor, which shall take into account the level of
18 screening applicable to a particular category of vendor under
19 federal law and regulations; (ii) by rule or provider notice,
20 the maximum length of the conditional enrollment period for
21 each category of risk of the vendor; and (iii) by rule, the
22 hearing rights, if any, afforded to a vendor in each category
23 of risk of the vendor that is terminated or disenrolled during
24 the conditional enrollment period.
25 To be eligible for payment consideration, a vendor's
26 payment claim or bill, either as an initial claim or as a
SB2437 Enrolled - 80 - LRB104 10548 KTG 20624 b
1 resubmitted claim following prior rejection, must be received
2 by the Illinois Department, or its fiscal intermediary, no
3 later than 180 days after the latest date on the claim on which
4 medical goods or services were provided, with the following
5 exceptions:
6 (1) In the case of a provider whose enrollment is in
7 process by the Illinois Department, the 180-day period
8 shall not begin until the date on the written notice from
9 the Illinois Department that the provider enrollment is
10 complete.
11 (2) In the case of errors attributable to the Illinois
12 Department or any of its claims processing intermediaries
13 which result in an inability to receive, process, or
14 adjudicate a claim, the 180-day period shall not begin
15 until the provider has been notified of the error.
16 (3) In the case of a provider for whom the Illinois
17 Department initiates the monthly billing process.
18 (4) In the case of a provider operated by a unit of
19 local government with a population exceeding 3,000,000
20 when local government funds finance federal participation
21 for claims payments.
22 For claims for services rendered during a period for which
23 a recipient received retroactive eligibility, claims must be
24 filed within 180 days after the Department determines the
25 applicant is eligible. For claims for which the Illinois
26 Department is not the primary payer, claims must be submitted
SB2437 Enrolled - 81 - LRB104 10548 KTG 20624 b
1 to the Illinois Department within 180 days after the final
2 adjudication by the primary payer.
3 In the case of long term care facilities, within 120
4 calendar days of receipt by the facility of required
5 prescreening information, new admissions with associated
6 admission documents shall be submitted through the Medical
7 Electronic Data Interchange (MEDI) or the Recipient
8 Eligibility Verification (REV) System or shall be submitted
9 directly to the Department of Human Services using required
10 admission forms. Effective September 1, 2014, admission
11 documents, including all prescreening information, must be
12 submitted through MEDI or REV. Confirmation numbers assigned
13 to an accepted transaction shall be retained by a facility to
14 verify timely submittal. Once an admission transaction has
15 been completed, all resubmitted claims following prior
16 rejection are subject to receipt no later than 180 days after
17 the admission transaction has been completed.
18 Claims that are not submitted and received in compliance
19 with the foregoing requirements shall not be eligible for
20 payment under the medical assistance program, and the State
21 shall have no liability for payment of those claims.
22 To the extent consistent with applicable information and
23 privacy, security, and disclosure laws, State and federal
24 agencies and departments shall provide the Illinois Department
25 access to confidential and other information and data
26 necessary to perform eligibility and payment verifications and
SB2437 Enrolled - 82 - LRB104 10548 KTG 20624 b
1 other Illinois Department functions. This includes, but is not
2 limited to: information pertaining to licensure;
3 certification; earnings; immigration status; citizenship; wage
4 reporting; unearned and earned income; pension income;
5 employment; supplemental security income; social security
6 numbers; National Provider Identifier (NPI) numbers; the
7 National Practitioner Data Bank (NPDB); program and agency
8 exclusions; taxpayer identification numbers; tax delinquency;
9 corporate information; and death records.
10 The Illinois Department shall enter into agreements with
11 State agencies and departments, and is authorized to enter
12 into agreements with federal agencies and departments, under
13 which such agencies and departments shall share data necessary
14 for medical assistance program integrity functions and
15 oversight. The Illinois Department shall develop, in
16 cooperation with other State departments and agencies, and in
17 compliance with applicable federal laws and regulations,
18 appropriate and effective methods to share such data. At a
19 minimum, and to the extent necessary to provide data sharing,
20 the Illinois Department shall enter into agreements with State
21 agencies and departments, and is authorized to enter into
22 agreements with federal agencies and departments, including,
23 but not limited to: the Secretary of State; the Department of
24 Revenue; the Department of Public Health; the Department of
25 Human Services; and the Department of Financial and
26 Professional Regulation.
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1 Beginning in fiscal year 2013, the Illinois Department
2 shall set forth a request for information to identify the
3 benefits of a pre-payment, post-adjudication, and post-edit
4 claims system with the goals of streamlining claims processing
5 and provider reimbursement, reducing the number of pending or
6 rejected claims, and helping to ensure a more transparent
7 adjudication process through the utilization of: (i) provider
8 data verification and provider screening technology; and (ii)
9 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
10 post-adjudicated predictive modeling with an integrated case
11 management system with link analysis. Such a request for
12 information shall not be considered as a request for proposal
13 or as an obligation on the part of the Illinois Department to
14 take any action or acquire any products or services.
15 The Illinois Department shall establish policies,
16 procedures, standards and criteria by rule for the
17 acquisition, repair and replacement of orthotic and prosthetic
18 devices and durable medical equipment. Such rules shall
19 provide, but not be limited to, the following services: (1)
20 immediate repair or replacement of such devices by recipients;
21 and (2) rental, lease, purchase or lease-purchase of durable
22 medical equipment in a cost-effective manner, taking into
23 consideration the recipient's medical prognosis, the extent of
24 the recipient's needs, and the requirements and costs for
25 maintaining such equipment. Subject to prior approval, such
26 rules shall enable a recipient to temporarily acquire and use
SB2437 Enrolled - 84 - LRB104 10548 KTG 20624 b
1 alternative or substitute devices or equipment pending repairs
2 or replacements of any device or equipment previously
3 authorized for such recipient by the Department.
4 Notwithstanding any provision of Section 5-5f to the contrary,
5 the Department may, by rule, exempt certain replacement
6 wheelchair parts from prior approval and, for wheelchairs,
7 wheelchair parts, wheelchair accessories, and related seating
8 and positioning items, determine the wholesale price by
9 methods other than actual acquisition costs.
10 The Department shall require, by rule, all providers of
11 durable medical equipment to be accredited by an accreditation
12 organization approved by the federal Centers for Medicare and
13 Medicaid Services and recognized by the Department in order to
14 bill the Department for providing durable medical equipment to
15 recipients. No later than 15 months after the effective date
16 of the rule adopted pursuant to this paragraph, all providers
17 must meet the accreditation requirement.
18 In order to promote environmental responsibility, meet the
19 needs of recipients and enrollees, and achieve significant
20 cost savings, the Department, or a managed care organization
21 under contract with the Department, may provide recipients or
22 managed care enrollees who have a prescription or Certificate
23 of Medical Necessity access to refurbished durable medical
24 equipment under this Section (excluding prosthetic and
25 orthotic devices as defined in the Orthotics, Prosthetics, and
26 Pedorthics Practice Act and complex rehabilitation technology
SB2437 Enrolled - 85 - LRB104 10548 KTG 20624 b
1 products and associated services) through the State's
2 assistive technology program's reutilization program, using
3 staff with the Assistive Technology Professional (ATP)
4 Certification if the refurbished durable medical equipment:
5 (i) is available; (ii) is less expensive, including shipping
6 costs, than new durable medical equipment of the same type;
7 (iii) is able to withstand at least 3 years of use; (iv) is
8 cleaned, disinfected, sterilized, and safe in accordance with
9 federal Food and Drug Administration regulations and guidance
10 governing the reprocessing of medical devices in health care
11 settings; and (v) equally meets the needs of the recipient or
12 enrollee. The reutilization program shall confirm that the
13 recipient or enrollee is not already in receipt of the same or
14 similar equipment from another service provider, and that the
15 refurbished durable medical equipment equally meets the needs
16 of the recipient or enrollee. Nothing in this paragraph shall
17 be construed to limit recipient or enrollee choice to obtain
18 new durable medical equipment or place any additional prior
19 authorization conditions on enrollees of managed care
20 organizations.
21 The Department shall execute, relative to the nursing home
22 prescreening project, written inter-agency agreements with the
23 Department of Human Services and the Department on Aging, to
24 effect the following: (i) intake procedures and common
25 eligibility criteria for those persons who are receiving
26 non-institutional services; and (ii) the establishment and
SB2437 Enrolled - 86 - LRB104 10548 KTG 20624 b
1 development of non-institutional services in areas of the
2 State where they are not currently available or are
3 undeveloped; and (iii) notwithstanding any other provision of
4 law, subject to federal approval, on and after July 1, 2012, an
5 increase in the determination of need (DON) scores from 29 to
6 37 for applicants for institutional and home and
7 community-based long term care; if and only if federal
8 approval is not granted, the Department may, in conjunction
9 with other affected agencies, implement utilization controls
10 or changes in benefit packages to effectuate a similar savings
11 amount for this population; and (iv) no later than July 1,
12 2013, minimum level of care eligibility criteria for
13 institutional and home and community-based long term care; and
14 (v) no later than October 1, 2013, establish procedures to
15 permit long term care providers access to eligibility scores
16 for individuals with an admission date who are seeking or
17 receiving services from the long term care provider. In order
18 to select the minimum level of care eligibility criteria, the
19 Governor shall establish a workgroup that includes affected
20 agency representatives and stakeholders representing the
21 institutional and home and community-based long term care
22 interests. This Section shall not restrict the Department from
23 implementing lower level of care eligibility criteria for
24 community-based services in circumstances where federal
25 approval has been granted.
26 The Illinois Department shall develop and operate, in
SB2437 Enrolled - 87 - LRB104 10548 KTG 20624 b
1 cooperation with other State Departments and agencies and in
2 compliance with applicable federal laws and regulations,
3 appropriate and effective systems of health care evaluation
4 and programs for monitoring of utilization of health care
5 services and facilities, as it affects persons eligible for
6 medical assistance under this Code.
7 The Illinois Department shall report annually to the
8 General Assembly, no later than the second Friday in April of
9 1979 and each year thereafter, in regard to:
10 (a) actual statistics and trends in utilization of
11 medical services by public aid recipients;
12 (b) actual statistics and trends in the provision of
13 the various medical services by medical vendors;
14 (c) current rate structures and proposed changes in
15 those rate structures for the various medical vendors; and
16 (d) efforts at utilization review and control by the
17 Illinois Department.
18 The period covered by each report shall be the 3 years
19 ending on the June 30 prior to the report. The report shall
20 include suggested legislation for consideration by the General
21 Assembly. The requirement for reporting to the General
22 Assembly shall be satisfied by filing copies of the report as
23 required by Section 3.1 of the General Assembly Organization
24 Act, and filing such additional copies with the State
25 Government Report Distribution Center for the General Assembly
26 as is required under paragraph (t) of Section 7 of the State
SB2437 Enrolled - 88 - LRB104 10548 KTG 20624 b
1 Library Act.
2 Rulemaking authority to implement Public Act 95-1045, if
3 any, is conditioned on the rules being adopted in accordance
4 with all provisions of the Illinois Administrative Procedure
5 Act and all rules and procedures of the Joint Committee on
6 Administrative Rules; any purported rule not so adopted, for
7 whatever reason, is unauthorized.
8 On and after July 1, 2012, the Department shall reduce any
9 rate of reimbursement for services or other payments or alter
10 any methodologies authorized by this Code to reduce any rate
11 of reimbursement for services or other payments in accordance
12 with Section 5-5e.
13 Because kidney transplantation can be an appropriate,
14 cost-effective alternative to renal dialysis when medically
15 necessary and notwithstanding the provisions of Section 1-11
16 of this Code, beginning October 1, 2014, the Department shall
17 cover kidney transplantation for noncitizens with end-stage
18 renal disease who are not eligible for comprehensive medical
19 benefits, who meet the residency requirements of Section 5-3
20 of this Code, and who would otherwise meet the financial
21 requirements of the appropriate class of eligible persons
22 under Section 5-2 of this Code. To qualify for coverage of
23 kidney transplantation, such person must be receiving
24 emergency renal dialysis services covered by the Department.
25 Providers under this Section shall be prior approved and
26 certified by the Department to perform kidney transplantation
SB2437 Enrolled - 89 - LRB104 10548 KTG 20624 b
1 and the services under this Section shall be limited to
2 services associated with kidney transplantation.
3 Notwithstanding any other provision of this Code to the
4 contrary, on or after July 1, 2015, all FDA-approved FDA
5 approved forms of medication assisted treatment prescribed for
6 the treatment of alcohol dependence or treatment of opioid
7 dependence shall be covered under both fee-for-service and
8 managed care medical assistance programs for persons who are
9 otherwise eligible for medical assistance under this Article
10 and shall not be subject to any (1) utilization control, other
11 than those established under the American Society of Addiction
12 Medicine patient placement criteria, (2) prior authorization
13 mandate, (3) lifetime restriction limit mandate, or (4)
14 limitations on dosage.
15 On or after July 1, 2015, opioid antagonists prescribed
16 for the treatment of an opioid overdose, including the
17 medication product, administration devices, and any pharmacy
18 fees or hospital fees related to the dispensing, distribution,
19 and administration of the opioid antagonist, shall be covered
20 under the medical assistance program for persons who are
21 otherwise eligible for medical assistance under this Article.
22 As used in this Section, "opioid antagonist" means a drug that
23 binds to opioid receptors and blocks or inhibits the effect of
24 opioids acting on those receptors, including, but not limited
25 to, naloxone hydrochloride or any other similarly acting drug
26 approved by the U.S. Food and Drug Administration. The
SB2437 Enrolled - 90 - LRB104 10548 KTG 20624 b
1 Department shall not impose a copayment on the coverage
2 provided for naloxone hydrochloride under the medical
3 assistance program.
4 Upon federal approval, the Department shall provide
5 coverage and reimbursement for all drugs that are approved for
6 marketing by the federal Food and Drug Administration and that
7 are recommended by the federal Public Health Service or the
8 United States Centers for Disease Control and Prevention for
9 pre-exposure prophylaxis and related pre-exposure prophylaxis
10 services, including, but not limited to, HIV and sexually
11 transmitted infection screening, treatment for sexually
12 transmitted infections, medical monitoring, assorted labs, and
13 counseling to reduce the likelihood of HIV infection among
14 individuals who are not infected with HIV but who are at high
15 risk of HIV infection.
16 A federally qualified health center, as defined in Section
17 1905(l)(2)(B) of the federal Social Security Act, shall be
18 reimbursed by the Department in accordance with the federally
19 qualified health center's encounter rate for services provided
20 to medical assistance recipients that are performed by a
21 dental hygienist, as defined under the Illinois Dental
22 Practice Act, working under the general supervision of a
23 dentist and employed by a federally qualified health center.
24 Within 90 days after October 8, 2021 (the effective date
25 of Public Act 102-665), the Department shall seek federal
26 approval of a State Plan amendment to expand coverage for
SB2437 Enrolled - 91 - LRB104 10548 KTG 20624 b
1 family planning services that includes presumptive eligibility
2 to individuals whose income is at or below 208% of the federal
3 poverty level. Coverage under this Section shall be effective
4 beginning no later than December 1, 2022.
5 Subject to approval by the federal Centers for Medicare
6 and Medicaid Services of a Title XIX State Plan amendment
7 electing the Program of All-Inclusive Care for the Elderly
8 (PACE) as a State Medicaid option, as provided for by Subtitle
9 I (commencing with Section 4801) of Title IV of the Balanced
10 Budget Act of 1997 (Public Law 105-33) and Part 460
11 (commencing with Section 460.2) of Subchapter E of Title 42 of
12 the Code of Federal Regulations, PACE program services shall
13 become a covered benefit of the medical assistance program,
14 subject to criteria established in accordance with all
15 applicable laws.
16 Notwithstanding any other provision of this Code,
17 community-based pediatric palliative care from a trained
18 interdisciplinary team shall be covered under the medical
19 assistance program as provided in Section 15 of the Pediatric
20 Palliative Care Act.
21 Notwithstanding any other provision of this Code, within
22 12 months after June 2, 2022 (the effective date of Public Act
23 102-1037) and subject to federal approval, acupuncture
24 services performed by an acupuncturist licensed under the
25 Acupuncture Practice Act who is acting within the scope of his
26 or her license shall be covered under the medical assistance
SB2437 Enrolled - 92 - LRB104 10548 KTG 20624 b
1 program. The Department shall apply for any federal waiver or
2 State Plan amendment, if required, to implement this
3 paragraph. The Department may adopt any rules, including
4 standards and criteria, necessary to implement this paragraph.
5 Notwithstanding any other provision of this Code, the
6 medical assistance program shall, subject to federal approval,
7 reimburse hospitals for costs associated with a newborn
8 screening test for the presence of metachromatic
9 leukodystrophy, as required under the Newborn Metabolic
10 Screening Act, at a rate not less than the fee charged by the
11 Department of Public Health. Notwithstanding any other
12 provision of this Code, the medical assistance program shall,
13 subject to appropriation and federal approval, also reimburse
14 hospitals for costs associated with all newborn screening
15 tests added on and after August 9, 2024 (the effective date of
16 Public Act 103-909) this amendatory Act of the 103rd General
17 Assembly to the Newborn Metabolic Screening Act and required
18 to be performed under that Act at a rate not less than the fee
19 charged by the Department of Public Health. The Department
20 shall seek federal approval before the implementation of the
21 newborn screening test fees by the Department of Public
22 Health.
23 Notwithstanding any other provision of this Code,
24 beginning on January 1, 2024, subject to federal approval,
25 cognitive assessment and care planning services provided to a
26 person who experiences signs or symptoms of cognitive
SB2437 Enrolled - 93 - LRB104 10548 KTG 20624 b
1 impairment, as defined by the Diagnostic and Statistical
2 Manual of Mental Disorders, Fifth Edition, shall be covered
3 under the medical assistance program for persons who are
4 otherwise eligible for medical assistance under this Article.
5 Notwithstanding any other provision of this Code,
6 medically necessary reconstructive services that are intended
7 to restore physical appearance shall be covered under the
8 medical assistance program for persons who are otherwise
9 eligible for medical assistance under this Article. As used in
10 this paragraph, "reconstructive services" means treatments
11 performed on structures of the body damaged by trauma to
12 restore physical appearance.
13 Subject to federal approval, for dates of services on and
14 after January 1, 2026, over-the-counter choline dietary
15 supplements for pregnant persons shall be covered under the
16 medical assistance program.
17 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
18 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
19 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
20 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
21 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
22 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
23 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
24 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
25 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
26 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
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1 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
2 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
3 10-10-24.)
4 (Text of Section after amendment by P.A. 103-808)
5 Sec. 5-5. Medical services. The Illinois Department, by
6 rule, shall determine the quantity and quality of and the rate
7 of reimbursement for the medical assistance for which payment
8 will be authorized, and the medical services to be provided,
9 which may include all or part of the following: (1) inpatient
10 hospital services; (2) outpatient hospital services; (3) other
11 laboratory and X-ray services; (4) skilled nursing home
12 services; (5) physicians' services whether furnished in the
13 office, the patient's home, a hospital, a skilled nursing
14 home, or elsewhere; (6) medical care, or any other type of
15 remedial care furnished by licensed practitioners; (7) home
16 health care services; (8) private duty nursing service; (9)
17 clinic services; (10) dental services, including prevention
18 and treatment of periodontal disease and dental caries disease
19 for pregnant individuals, provided by an individual licensed
20 to practice dentistry or dental surgery; for purposes of this
21 item (10), "dental services" means diagnostic, preventive, or
22 corrective procedures provided by or under the supervision of
23 a dentist in the practice of his or her profession; (11)
24 physical therapy and related services; (12) prescribed drugs,
25 dentures, and prosthetic devices; and eyeglasses prescribed by
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1 a physician skilled in the diseases of the eye, or by an
2 optometrist, whichever the person may select; (13) other
3 diagnostic, screening, preventive, and rehabilitative
4 services, including to ensure that the individual's need for
5 intervention or treatment of mental disorders or substance use
6 disorders or co-occurring mental health and substance use
7 disorders is determined using a uniform screening, assessment,
8 and evaluation process inclusive of criteria, for children and
9 adults; for purposes of this item (13), a uniform screening,
10 assessment, and evaluation process refers to a process that
11 includes an appropriate evaluation and, as warranted, a
12 referral; "uniform" does not mean the use of a singular
13 instrument, tool, or process that all must utilize; (14)
14 transportation and such other expenses as may be necessary;
15 (15) medical treatment of sexual assault survivors, as defined
16 in Section 1a of the Sexual Assault Survivors Emergency
17 Treatment Act, for injuries sustained as a result of the
18 sexual assault, including examinations and laboratory tests to
19 discover evidence which may be used in criminal proceedings
20 arising from the sexual assault; (16) the diagnosis and
21 treatment of sickle cell anemia; (16.5) services performed by
22 a chiropractic physician licensed under the Medical Practice
23 Act of 1987 and acting within the scope of his or her license,
24 including, but not limited to, chiropractic manipulative
25 treatment; and (17) any other medical care, and any other type
26 of remedial care recognized under the laws of this State. The
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1 term "any other type of remedial care" shall include nursing
2 care and nursing home service for persons who rely on
3 treatment by spiritual means alone through prayer for healing.
4 Notwithstanding any other provision of this Section, a
5 comprehensive tobacco use cessation program that includes
6 purchasing prescription drugs or prescription medical devices
7 approved by the Food and Drug Administration shall be covered
8 under the medical assistance program under this Article for
9 persons who are otherwise eligible for assistance under this
10 Article.
11 Notwithstanding any other provision of this Code,
12 reproductive health care that is otherwise legal in Illinois
13 shall be covered under the medical assistance program for
14 persons who are otherwise eligible for medical assistance
15 under this Article.
16 Notwithstanding any other provision of this Section, all
17 tobacco cessation medications approved by the United States
18 Food and Drug Administration and all individual and group
19 tobacco cessation counseling services and telephone-based
20 counseling services and tobacco cessation medications provided
21 through the Illinois Tobacco Quitline shall be covered under
22 the medical assistance program for persons who are otherwise
23 eligible for assistance under this Article. The Department
24 shall comply with all federal requirements necessary to obtain
25 federal financial participation, as specified in 42 CFR
26 433.15(b)(7), for telephone-based counseling services provided
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1 through the Illinois Tobacco Quitline, including, but not
2 limited to: (i) entering into a memorandum of understanding or
3 interagency agreement with the Department of Public Health, as
4 administrator of the Illinois Tobacco Quitline; and (ii)
5 developing a cost allocation plan for Medicaid-allowable
6 Illinois Tobacco Quitline services in accordance with 45 CFR
7 95.507. The Department shall submit the memorandum of
8 understanding or interagency agreement, the cost allocation
9 plan, and all other necessary documentation to the Centers for
10 Medicare and Medicaid Services for review and approval.
11 Coverage under this paragraph shall be contingent upon federal
12 approval.
13 Notwithstanding any other provision of this Code, the
14 Illinois Department may not require, as a condition of payment
15 for any laboratory test authorized under this Article, that a
16 physician's handwritten signature appear on the laboratory
17 test order form. The Illinois Department may, however, impose
18 other appropriate requirements regarding laboratory test order
19 documentation.
20 Upon receipt of federal approval of an amendment to the
21 Illinois Title XIX State Plan for this purpose, the Department
22 shall authorize the Chicago Public Schools (CPS) to procure a
23 vendor or vendors to manufacture eyeglasses for individuals
24 enrolled in a school within the CPS system. CPS shall ensure
25 that its vendor or vendors are enrolled as providers in the
26 medical assistance program and in any capitated Medicaid
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1 managed care entity (MCE) serving individuals enrolled in a
2 school within the CPS system. Under any contract procured
3 under this provision, the vendor or vendors must serve only
4 individuals enrolled in a school within the CPS system. Claims
5 for services provided by CPS's vendor or vendors to recipients
6 of benefits in the medical assistance program under this Code,
7 the Children's Health Insurance Program, or the Covering ALL
8 KIDS Health Insurance Program shall be submitted to the
9 Department or the MCE in which the individual is enrolled for
10 payment and shall be reimbursed at the Department's or the
11 MCE's established rates or rate methodologies for eyeglasses.
12 On and after July 1, 2012, the Department of Healthcare
13 and Family Services may provide the following services to
14 persons eligible for assistance under this Article who are
15 participating in education, training or employment programs
16 operated by the Department of Human Services as successor to
17 the Department of Public Aid:
18 (1) dental services provided by or under the
19 supervision of a dentist; and
20 (2) eyeglasses prescribed by a physician skilled in
21 the diseases of the eye, or by an optometrist, whichever
22 the person may select.
23 On and after July 1, 2018, the Department of Healthcare
24 and Family Services shall provide dental services to any adult
25 who is otherwise eligible for assistance under the medical
26 assistance program. As used in this paragraph, "dental
SB2437 Enrolled - 99 - LRB104 10548 KTG 20624 b
1 services" means diagnostic, preventative, restorative, or
2 corrective procedures, including procedures and services for
3 the prevention and treatment of periodontal disease and dental
4 caries disease, provided by an individual who is licensed to
5 practice dentistry or dental surgery or who is under the
6 supervision of a dentist in the practice of his or her
7 profession.
8 On and after July 1, 2018, targeted dental services, as
9 set forth in Exhibit D of the Consent Decree entered by the
10 United States District Court for the Northern District of
11 Illinois, Eastern Division, in the matter of Memisovski v.
12 Maram, Case No. 92 C 1982, that are provided to adults under
13 the medical assistance program shall be established at no less
14 than the rates set forth in the "New Rate" column in Exhibit D
15 of the Consent Decree for targeted dental services that are
16 provided to persons under the age of 18 under the medical
17 assistance program.
18 Subject to federal approval, on and after January 1, 2025,
19 the rates paid for sedation evaluation and the provision of
20 deep sedation and intravenous sedation for the purpose of
21 dental services shall be increased by 33% above the rates in
22 effect on December 31, 2024. The rates paid for nitrous oxide
23 sedation shall not be impacted by this paragraph and shall
24 remain the same as the rates in effect on December 31, 2024.
25 Notwithstanding any other provision of this Code and
26 subject to federal approval, the Department may adopt rules to
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1 allow a dentist who is volunteering his or her service at no
2 cost to render dental services through an enrolled
3 not-for-profit health clinic without the dentist personally
4 enrolling as a participating provider in the medical
5 assistance program. A not-for-profit health clinic shall
6 include a public health clinic or Federally Qualified Health
7 Center or other enrolled provider, as determined by the
8 Department, through which dental services covered under this
9 Section are performed. The Department shall establish a
10 process for payment of claims for reimbursement for covered
11 dental services rendered under this provision.
12 Subject to appropriation and to federal approval, the
13 Department shall file administrative rules updating the
14 Handicapping Labio-Lingual Deviation orthodontic scoring tool
15 by January 1, 2025, or as soon as practicable.
16 On and after January 1, 2022, the Department of Healthcare
17 and Family Services shall administer and regulate a
18 school-based dental program that allows for the out-of-office
19 delivery of preventative dental services in a school setting
20 to children under 19 years of age. The Department shall
21 establish, by rule, guidelines for participation by providers
22 and set requirements for follow-up referral care based on the
23 requirements established in the Dental Office Reference Manual
24 published by the Department that establishes the requirements
25 for dentists participating in the All Kids Dental School
26 Program. Every effort shall be made by the Department when
SB2437 Enrolled - 101 - LRB104 10548 KTG 20624 b
1 developing the program requirements to consider the different
2 geographic differences of both urban and rural areas of the
3 State for initial treatment and necessary follow-up care. No
4 provider shall be charged a fee by any unit of local government
5 to participate in the school-based dental program administered
6 by the Department. Nothing in this paragraph shall be
7 construed to limit or preempt a home rule unit's or school
8 district's authority to establish, change, or administer a
9 school-based dental program in addition to, or independent of,
10 the school-based dental program administered by the
11 Department.
12 The Illinois Department, by rule, may distinguish and
13 classify the medical services to be provided only in
14 accordance with the classes of persons designated in Section
15 5-2.
16 The Department of Healthcare and Family Services must
17 provide coverage and reimbursement for amino acid-based
18 elemental formulas, regardless of delivery method, for the
19 diagnosis and treatment of (i) eosinophilic disorders and (ii)
20 short bowel syndrome when the prescribing physician has issued
21 a written order stating that the amino acid-based elemental
22 formula is medically necessary.
23 The Illinois Department shall authorize the provision of,
24 and shall authorize payment for, screening by low-dose
25 mammography for the presence of occult breast cancer for
26 individuals 35 years of age or older who are eligible for
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1 medical assistance under this Article, as follows:
2 (A) A baseline mammogram for individuals 35 to 39
3 years of age.
4 (B) An annual mammogram for individuals 40 years of
5 age or older.
6 (C) A mammogram at the age and intervals considered
7 medically necessary by the individual's health care
8 provider for individuals under 40 years of age and having
9 a family history of breast cancer, prior personal history
10 of breast cancer, positive genetic testing, or other risk
11 factors.
12 (D) A comprehensive ultrasound screening and MRI of an
13 entire breast or breasts if a mammogram demonstrates
14 heterogeneous or dense breast tissue or when medically
15 necessary as determined by a physician licensed to
16 practice medicine in all of its branches.
17 (E) A screening MRI when medically necessary, as
18 determined by a physician licensed to practice medicine in
19 all of its branches.
20 (F) A diagnostic mammogram when medically necessary,
21 as determined by a physician licensed to practice medicine
22 in all its branches, advanced practice registered nurse,
23 or physician assistant.
24 (G) Molecular breast imaging (MBI) and MRI of an
25 entire breast or breasts if a mammogram demonstrates
26 heterogeneous or dense breast tissue or when medically
SB2437 Enrolled - 103 - LRB104 10548 KTG 20624 b
1 necessary as determined by a physician licensed to
2 practice medicine in all of its branches, advanced
3 practice registered nurse, or physician assistant.
4 The Department shall not impose a deductible, coinsurance,
5 copayment, or any other cost-sharing requirement on the
6 coverage provided under this paragraph; except that this
7 sentence does not apply to coverage of diagnostic mammograms
8 to the extent such coverage would disqualify a high-deductible
9 health plan from eligibility for a health savings account
10 pursuant to Section 223 of the Internal Revenue Code (26
11 U.S.C. 223).
12 All screenings shall include a physical breast exam,
13 instruction on self-examination and information regarding the
14 frequency of self-examination and its value as a preventative
15 tool.
16 For purposes of this Section:
17 "Diagnostic mammogram" means a mammogram obtained using
18 diagnostic mammography.
19 "Diagnostic mammography" means a method of screening that
20 is designed to evaluate an abnormality in a breast, including
21 an abnormality seen or suspected on a screening mammogram or a
22 subjective or objective abnormality otherwise detected in the
23 breast.
24 "Low-dose mammography" means the x-ray examination of the
25 breast using equipment dedicated specifically for mammography,
26 including the x-ray tube, filter, compression device, and
SB2437 Enrolled - 104 - LRB104 10548 KTG 20624 b
1 image receptor, with an average radiation exposure delivery of
2 less than one rad per breast for 2 views of an average size
3 breast. The term also includes digital mammography and
4 includes breast tomosynthesis.
5 "Breast tomosynthesis" means a radiologic procedure that
6 involves the acquisition of projection images over the
7 stationary breast to produce cross-sectional digital
8 three-dimensional images of the breast.
9 If, at any time, the Secretary of the United States
10 Department of Health and Human Services, or its successor
11 agency, promulgates rules or regulations to be published in
12 the Federal Register or publishes a comment in the Federal
13 Register or issues an opinion, guidance, or other action that
14 would require the State, pursuant to any provision of the
15 Patient Protection and Affordable Care Act (Public Law
16 111-148), including, but not limited to, 42 U.S.C.
17 18031(d)(3)(B) or any successor provision, to defray the cost
18 of any coverage for breast tomosynthesis outlined in this
19 paragraph, then the requirement that an insurer cover breast
20 tomosynthesis is inoperative other than any such coverage
21 authorized under Section 1902 of the Social Security Act, 42
22 U.S.C. 1396a, and the State shall not assume any obligation
23 for the cost of coverage for breast tomosynthesis set forth in
24 this paragraph.
25 On and after January 1, 2016, the Department shall ensure
26 that all networks of care for adult clients of the Department
SB2437 Enrolled - 105 - LRB104 10548 KTG 20624 b
1 include access to at least one breast imaging Center of
2 Imaging Excellence as certified by the American College of
3 Radiology.
4 On and after January 1, 2012, providers participating in a
5 quality improvement program approved by the Department shall
6 be reimbursed for screening and diagnostic mammography at the
7 same rate as the Medicare program's rates, including the
8 increased reimbursement for digital mammography and, after
9 January 1, 2023 (the effective date of Public Act 102-1018),
10 breast tomosynthesis.
11 The Department shall convene an expert panel including
12 representatives of hospitals, free-standing mammography
13 facilities, and doctors, including radiologists, to establish
14 quality standards for mammography.
15 On and after January 1, 2017, providers participating in a
16 breast cancer treatment quality improvement program approved
17 by the Department shall be reimbursed for breast cancer
18 treatment at a rate that is no lower than 95% of the Medicare
19 program's rates for the data elements included in the breast
20 cancer treatment quality program.
21 The Department shall convene an expert panel, including
22 representatives of hospitals, free-standing breast cancer
23 treatment centers, breast cancer quality organizations, and
24 doctors, including radiologists that are trained in all forms
25 of FDA-approved FDA approved breast imaging technologies,
26 breast surgeons, reconstructive breast surgeons, oncologists,
SB2437 Enrolled - 106 - LRB104 10548 KTG 20624 b
1 and primary care providers to establish quality standards for
2 breast cancer treatment.
3 Subject to federal approval, the Department shall
4 establish a rate methodology for mammography at federally
5 qualified health centers and other encounter-rate clinics.
6 These clinics or centers may also collaborate with other
7 hospital-based mammography facilities. By January 1, 2016, the
8 Department shall report to the General Assembly on the status
9 of the provision set forth in this paragraph.
10 The Department shall establish a methodology to remind
11 individuals who are age-appropriate for screening mammography,
12 but who have not received a mammogram within the previous 18
13 months, of the importance and benefit of screening
14 mammography. The Department shall work with experts in breast
15 cancer outreach and patient navigation to optimize these
16 reminders and shall establish a methodology for evaluating
17 their effectiveness and modifying the methodology based on the
18 evaluation.
19 The Department shall establish a performance goal for
20 primary care providers with respect to their female patients
21 over age 40 receiving an annual mammogram. This performance
22 goal shall be used to provide additional reimbursement in the
23 form of a quality performance bonus to primary care providers
24 who meet that goal.
25 The Department shall devise a means of case-managing or
26 patient navigation for beneficiaries diagnosed with breast
SB2437 Enrolled - 107 - LRB104 10548 KTG 20624 b
1 cancer. This program shall initially operate as a pilot
2 program in areas of the State with the highest incidence of
3 mortality related to breast cancer. At least one pilot program
4 site shall be in the metropolitan Chicago area and at least one
5 site shall be outside the metropolitan Chicago area. On or
6 after July 1, 2016, the pilot program shall be expanded to
7 include one site in western Illinois, one site in southern
8 Illinois, one site in central Illinois, and 4 sites within
9 metropolitan Chicago. An evaluation of the pilot program shall
10 be carried out measuring health outcomes and cost of care for
11 those served by the pilot program compared to similarly
12 situated patients who are not served by the pilot program.
13 The Department shall require all networks of care to
14 develop a means either internally or by contract with experts
15 in navigation and community outreach to navigate cancer
16 patients to comprehensive care in a timely fashion. The
17 Department shall require all networks of care to include
18 access for patients diagnosed with cancer to at least one
19 academic commission on cancer-accredited cancer program as an
20 in-network covered benefit.
21 The Department shall provide coverage and reimbursement
22 for a human papillomavirus (HPV) vaccine that is approved for
23 marketing by the federal Food and Drug Administration for all
24 persons between the ages of 9 and 45. Subject to federal
25 approval, the Department shall provide coverage and
26 reimbursement for a human papillomavirus (HPV) vaccine for
SB2437 Enrolled - 108 - LRB104 10548 KTG 20624 b
1 persons of the age of 46 and above who have been diagnosed with
2 cervical dysplasia with a high risk of recurrence or
3 progression. The Department shall disallow any
4 preauthorization requirements for the administration of the
5 human papillomavirus (HPV) vaccine.
6 On or after July 1, 2022, individuals who are otherwise
7 eligible for medical assistance under this Article shall
8 receive coverage for perinatal depression screenings for the
9 12-month period beginning on the last day of their pregnancy.
10 Medical assistance coverage under this paragraph shall be
11 conditioned on the use of a screening instrument approved by
12 the Department.
13 Any medical or health care provider shall immediately
14 recommend, to any pregnant individual who is being provided
15 prenatal services and is suspected of having a substance use
16 disorder as defined in the Substance Use Disorder Act,
17 referral to a local substance use disorder treatment program
18 licensed by the Department of Human Services or to a licensed
19 hospital which provides substance abuse treatment services.
20 The Department of Healthcare and Family Services shall assure
21 coverage for the cost of treatment of the drug abuse or
22 addiction for pregnant recipients in accordance with the
23 Illinois Medicaid Program in conjunction with the Department
24 of Human Services.
25 All medical providers providing medical assistance to
26 pregnant individuals under this Code shall receive information
SB2437 Enrolled - 109 - LRB104 10548 KTG 20624 b
1 from the Department on the availability of services under any
2 program providing case management services for addicted
3 individuals, including information on appropriate referrals
4 for other social services that may be needed by addicted
5 individuals in addition to treatment for addiction.
6 The Illinois Department, in cooperation with the
7 Departments of Human Services (as successor to the Department
8 of Alcoholism and Substance Abuse) and Public Health, through
9 a public awareness campaign, may provide information
10 concerning treatment for alcoholism and drug abuse and
11 addiction, prenatal health care, and other pertinent programs
12 directed at reducing the number of drug-affected infants born
13 to recipients of medical assistance.
14 Neither the Department of Healthcare and Family Services
15 nor the Department of Human Services shall sanction the
16 recipient solely on the basis of the recipient's substance
17 abuse.
18 The Illinois Department shall establish such regulations
19 governing the dispensing of health services under this Article
20 as it shall deem appropriate. The Department should seek the
21 advice of formal professional advisory committees appointed by
22 the Director of the Illinois Department for the purpose of
23 providing regular advice on policy and administrative matters,
24 information dissemination and educational activities for
25 medical and health care providers, and consistency in
26 procedures to the Illinois Department.
SB2437 Enrolled - 110 - LRB104 10548 KTG 20624 b
1 The Illinois Department may develop and contract with
2 Partnerships of medical providers to arrange medical services
3 for persons eligible under Section 5-2 of this Code.
4 Implementation of this Section may be by demonstration
5 projects in certain geographic areas. The Partnership shall be
6 represented by a sponsor organization. The Department, by
7 rule, shall develop qualifications for sponsors of
8 Partnerships. Nothing in this Section shall be construed to
9 require that the sponsor organization be a medical
10 organization.
11 The sponsor must negotiate formal written contracts with
12 medical providers for physician services, inpatient and
13 outpatient hospital care, home health services, treatment for
14 alcoholism and substance abuse, and other services determined
15 necessary by the Illinois Department by rule for delivery by
16 Partnerships. Physician services must include prenatal and
17 obstetrical care. The Illinois Department shall reimburse
18 medical services delivered by Partnership providers to clients
19 in target areas according to provisions of this Article and
20 the Illinois Health Finance Reform Act, except that:
21 (1) Physicians participating in a Partnership and
22 providing certain services, which shall be determined by
23 the Illinois Department, to persons in areas covered by
24 the Partnership may receive an additional surcharge for
25 such services.
26 (2) The Department may elect to consider and negotiate
SB2437 Enrolled - 111 - LRB104 10548 KTG 20624 b
1 financial incentives to encourage the development of
2 Partnerships and the efficient delivery of medical care.
3 (3) Persons receiving medical services through
4 Partnerships may receive medical and case management
5 services above the level usually offered through the
6 medical assistance program.
7 Medical providers shall be required to meet certain
8 qualifications to participate in Partnerships to ensure the
9 delivery of high quality medical services. These
10 qualifications shall be determined by rule of the Illinois
11 Department and may be higher than qualifications for
12 participation in the medical assistance program. Partnership
13 sponsors may prescribe reasonable additional qualifications
14 for participation by medical providers, only with the prior
15 written approval of the Illinois Department.
16 Nothing in this Section shall limit the free choice of
17 practitioners, hospitals, and other providers of medical
18 services by clients. In order to ensure patient freedom of
19 choice, the Illinois Department shall immediately promulgate
20 all rules and take all other necessary actions so that
21 provided services may be accessed from therapeutically
22 certified optometrists to the full extent of the Illinois
23 Optometric Practice Act of 1987 without discriminating between
24 service providers.
25 The Department shall apply for a waiver from the United
26 States Health Care Financing Administration to allow for the
SB2437 Enrolled - 112 - LRB104 10548 KTG 20624 b
1 implementation of Partnerships under this Section.
2 The Illinois Department shall require health care
3 providers to maintain records that document the medical care
4 and services provided to recipients of Medical Assistance
5 under this Article. Such records must be retained for a period
6 of not less than 6 years from the date of service or as
7 provided by applicable State law, whichever period is longer,
8 except that if an audit is initiated within the required
9 retention period then the records must be retained until the
10 audit is completed and every exception is resolved. The
11 Illinois Department shall require health care providers to
12 make available, when authorized by the patient, in writing,
13 the medical records in a timely fashion to other health care
14 providers who are treating or serving persons eligible for
15 Medical Assistance under this Article. All dispensers of
16 medical services shall be required to maintain and retain
17 business and professional records sufficient to fully and
18 accurately document the nature, scope, details and receipt of
19 the health care provided to persons eligible for medical
20 assistance under this Code, in accordance with regulations
21 promulgated by the Illinois Department. The rules and
22 regulations shall require that proof of the receipt of
23 prescription drugs, dentures, prosthetic devices and
24 eyeglasses by eligible persons under this Section accompany
25 each claim for reimbursement submitted by the dispenser of
26 such medical services. No such claims for reimbursement shall
SB2437 Enrolled - 113 - LRB104 10548 KTG 20624 b
1 be approved for payment by the Illinois Department without
2 such proof of receipt, unless the Illinois Department shall
3 have put into effect and shall be operating a system of
4 post-payment audit and review which shall, on a sampling
5 basis, be deemed adequate by the Illinois Department to assure
6 that such drugs, dentures, prosthetic devices and eyeglasses
7 for which payment is being made are actually being received by
8 eligible recipients. Within 90 days after September 16, 1984
9 (the effective date of Public Act 83-1439), the Illinois
10 Department shall establish a current list of acquisition costs
11 for all prosthetic devices and any other items recognized as
12 medical equipment and supplies reimbursable under this Article
13 and shall update such list on a quarterly basis, except that
14 the acquisition costs of all prescription drugs shall be
15 updated no less frequently than every 30 days as required by
16 Section 5-5.12.
17 Notwithstanding any other law to the contrary, the
18 Illinois Department shall, within 365 days after July 22, 2013
19 (the effective date of Public Act 98-104), establish
20 procedures to permit skilled care facilities licensed under
21 the Nursing Home Care Act to submit monthly billing claims for
22 reimbursement purposes. Following development of these
23 procedures, the Department shall, by July 1, 2016, test the
24 viability of the new system and implement any necessary
25 operational or structural changes to its information
26 technology platforms in order to allow for the direct
SB2437 Enrolled - 114 - LRB104 10548 KTG 20624 b
1 acceptance and payment of nursing home claims.
2 Notwithstanding any other law to the contrary, the
3 Illinois Department shall, within 365 days after August 15,
4 2014 (the effective date of Public Act 98-963), establish
5 procedures to permit ID/DD facilities licensed under the ID/DD
6 Community Care Act and MC/DD facilities licensed under the
7 MC/DD Act to submit monthly billing claims for reimbursement
8 purposes. Following development of these procedures, the
9 Department shall have an additional 365 days to test the
10 viability of the new system and to ensure that any necessary
11 operational or structural changes to its information
12 technology platforms are implemented.
13 The Illinois Department shall require all dispensers of
14 medical services, other than an individual practitioner or
15 group of practitioners, desiring to participate in the Medical
16 Assistance program established under this Article to disclose
17 all financial, beneficial, ownership, equity, surety or other
18 interests in any and all firms, corporations, partnerships,
19 associations, business enterprises, joint ventures, agencies,
20 institutions or other legal entities providing any form of
21 health care services in this State under this Article.
22 The Illinois Department may require that all dispensers of
23 medical services desiring to participate in the medical
24 assistance program established under this Article disclose,
25 under such terms and conditions as the Illinois Department may
26 by rule establish, all inquiries from clients and attorneys
SB2437 Enrolled - 115 - LRB104 10548 KTG 20624 b
1 regarding medical bills paid by the Illinois Department, which
2 inquiries could indicate potential existence of claims or
3 liens for the Illinois Department.
4 Enrollment of a vendor shall be subject to a provisional
5 period and shall be conditional for one year. During the
6 period of conditional enrollment, the Department may terminate
7 the vendor's eligibility to participate in, or may disenroll
8 the vendor from, the medical assistance program without cause.
9 Unless otherwise specified, such termination of eligibility or
10 disenrollment is not subject to the Department's hearing
11 process. However, a disenrolled vendor may reapply without
12 penalty.
13 The Department has the discretion to limit the conditional
14 enrollment period for vendors based upon the category of risk
15 of the vendor.
16 Prior to enrollment and during the conditional enrollment
17 period in the medical assistance program, all vendors shall be
18 subject to enhanced oversight, screening, and review based on
19 the risk of fraud, waste, and abuse that is posed by the
20 category of risk of the vendor. The Illinois Department shall
21 establish the procedures for oversight, screening, and review,
22 which may include, but need not be limited to: criminal and
23 financial background checks; fingerprinting; license,
24 certification, and authorization verifications; unscheduled or
25 unannounced site visits; database checks; prepayment audit
26 reviews; audits; payment caps; payment suspensions; and other
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1 screening as required by federal or State law.
2 The Department shall define or specify the following: (i)
3 by provider notice, the "category of risk of the vendor" for
4 each type of vendor, which shall take into account the level of
5 screening applicable to a particular category of vendor under
6 federal law and regulations; (ii) by rule or provider notice,
7 the maximum length of the conditional enrollment period for
8 each category of risk of the vendor; and (iii) by rule, the
9 hearing rights, if any, afforded to a vendor in each category
10 of risk of the vendor that is terminated or disenrolled during
11 the conditional enrollment period.
12 To be eligible for payment consideration, a vendor's
13 payment claim or bill, either as an initial claim or as a
14 resubmitted claim following prior rejection, must be received
15 by the Illinois Department, or its fiscal intermediary, no
16 later than 180 days after the latest date on the claim on which
17 medical goods or services were provided, with the following
18 exceptions:
19 (1) In the case of a provider whose enrollment is in
20 process by the Illinois Department, the 180-day period
21 shall not begin until the date on the written notice from
22 the Illinois Department that the provider enrollment is
23 complete.
24 (2) In the case of errors attributable to the Illinois
25 Department or any of its claims processing intermediaries
26 which result in an inability to receive, process, or
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1 adjudicate a claim, the 180-day period shall not begin
2 until the provider has been notified of the error.
3 (3) In the case of a provider for whom the Illinois
4 Department initiates the monthly billing process.
5 (4) In the case of a provider operated by a unit of
6 local government with a population exceeding 3,000,000
7 when local government funds finance federal participation
8 for claims payments.
9 For claims for services rendered during a period for which
10 a recipient received retroactive eligibility, claims must be
11 filed within 180 days after the Department determines the
12 applicant is eligible. For claims for which the Illinois
13 Department is not the primary payer, claims must be submitted
14 to the Illinois Department within 180 days after the final
15 adjudication by the primary payer.
16 In the case of long term care facilities, within 120
17 calendar days of receipt by the facility of required
18 prescreening information, new admissions with associated
19 admission documents shall be submitted through the Medical
20 Electronic Data Interchange (MEDI) or the Recipient
21 Eligibility Verification (REV) System or shall be submitted
22 directly to the Department of Human Services using required
23 admission forms. Effective September 1, 2014, admission
24 documents, including all prescreening information, must be
25 submitted through MEDI or REV. Confirmation numbers assigned
26 to an accepted transaction shall be retained by a facility to
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1 verify timely submittal. Once an admission transaction has
2 been completed, all resubmitted claims following prior
3 rejection are subject to receipt no later than 180 days after
4 the admission transaction has been completed.
5 Claims that are not submitted and received in compliance
6 with the foregoing requirements shall not be eligible for
7 payment under the medical assistance program, and the State
8 shall have no liability for payment of those claims.
9 To the extent consistent with applicable information and
10 privacy, security, and disclosure laws, State and federal
11 agencies and departments shall provide the Illinois Department
12 access to confidential and other information and data
13 necessary to perform eligibility and payment verifications and
14 other Illinois Department functions. This includes, but is not
15 limited to: information pertaining to licensure;
16 certification; earnings; immigration status; citizenship; wage
17 reporting; unearned and earned income; pension income;
18 employment; supplemental security income; social security
19 numbers; National Provider Identifier (NPI) numbers; the
20 National Practitioner Data Bank (NPDB); program and agency
21 exclusions; taxpayer identification numbers; tax delinquency;
22 corporate information; and death records.
23 The Illinois Department shall enter into agreements with
24 State agencies and departments, and is authorized to enter
25 into agreements with federal agencies and departments, under
26 which such agencies and departments shall share data necessary
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1 for medical assistance program integrity functions and
2 oversight. The Illinois Department shall develop, in
3 cooperation with other State departments and agencies, and in
4 compliance with applicable federal laws and regulations,
5 appropriate and effective methods to share such data. At a
6 minimum, and to the extent necessary to provide data sharing,
7 the Illinois Department shall enter into agreements with State
8 agencies and departments, and is authorized to enter into
9 agreements with federal agencies and departments, including,
10 but not limited to: the Secretary of State; the Department of
11 Revenue; the Department of Public Health; the Department of
12 Human Services; and the Department of Financial and
13 Professional Regulation.
14 Beginning in fiscal year 2013, the Illinois Department
15 shall set forth a request for information to identify the
16 benefits of a pre-payment, post-adjudication, and post-edit
17 claims system with the goals of streamlining claims processing
18 and provider reimbursement, reducing the number of pending or
19 rejected claims, and helping to ensure a more transparent
20 adjudication process through the utilization of: (i) provider
21 data verification and provider screening technology; and (ii)
22 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
23 post-adjudicated predictive modeling with an integrated case
24 management system with link analysis. Such a request for
25 information shall not be considered as a request for proposal
26 or as an obligation on the part of the Illinois Department to
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1 take any action or acquire any products or services.
2 The Illinois Department shall establish policies,
3 procedures, standards and criteria by rule for the
4 acquisition, repair and replacement of orthotic and prosthetic
5 devices and durable medical equipment. Such rules shall
6 provide, but not be limited to, the following services: (1)
7 immediate repair or replacement of such devices by recipients;
8 and (2) rental, lease, purchase or lease-purchase of durable
9 medical equipment in a cost-effective manner, taking into
10 consideration the recipient's medical prognosis, the extent of
11 the recipient's needs, and the requirements and costs for
12 maintaining such equipment. Subject to prior approval, such
13 rules shall enable a recipient to temporarily acquire and use
14 alternative or substitute devices or equipment pending repairs
15 or replacements of any device or equipment previously
16 authorized for such recipient by the Department.
17 Notwithstanding any provision of Section 5-5f to the contrary,
18 the Department may, by rule, exempt certain replacement
19 wheelchair parts from prior approval and, for wheelchairs,
20 wheelchair parts, wheelchair accessories, and related seating
21 and positioning items, determine the wholesale price by
22 methods other than actual acquisition costs.
23 The Department shall require, by rule, all providers of
24 durable medical equipment to be accredited by an accreditation
25 organization approved by the federal Centers for Medicare and
26 Medicaid Services and recognized by the Department in order to
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1 bill the Department for providing durable medical equipment to
2 recipients. No later than 15 months after the effective date
3 of the rule adopted pursuant to this paragraph, all providers
4 must meet the accreditation requirement.
5 In order to promote environmental responsibility, meet the
6 needs of recipients and enrollees, and achieve significant
7 cost savings, the Department, or a managed care organization
8 under contract with the Department, may provide recipients or
9 managed care enrollees who have a prescription or Certificate
10 of Medical Necessity access to refurbished durable medical
11 equipment under this Section (excluding prosthetic and
12 orthotic devices as defined in the Orthotics, Prosthetics, and
13 Pedorthics Practice Act and complex rehabilitation technology
14 products and associated services) through the State's
15 assistive technology program's reutilization program, using
16 staff with the Assistive Technology Professional (ATP)
17 Certification if the refurbished durable medical equipment:
18 (i) is available; (ii) is less expensive, including shipping
19 costs, than new durable medical equipment of the same type;
20 (iii) is able to withstand at least 3 years of use; (iv) is
21 cleaned, disinfected, sterilized, and safe in accordance with
22 federal Food and Drug Administration regulations and guidance
23 governing the reprocessing of medical devices in health care
24 settings; and (v) equally meets the needs of the recipient or
25 enrollee. The reutilization program shall confirm that the
26 recipient or enrollee is not already in receipt of the same or
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1 similar equipment from another service provider, and that the
2 refurbished durable medical equipment equally meets the needs
3 of the recipient or enrollee. Nothing in this paragraph shall
4 be construed to limit recipient or enrollee choice to obtain
5 new durable medical equipment or place any additional prior
6 authorization conditions on enrollees of managed care
7 organizations.
8 The Department shall execute, relative to the nursing home
9 prescreening project, written inter-agency agreements with the
10 Department of Human Services and the Department on Aging, to
11 effect the following: (i) intake procedures and common
12 eligibility criteria for those persons who are receiving
13 non-institutional services; and (ii) the establishment and
14 development of non-institutional services in areas of the
15 State where they are not currently available or are
16 undeveloped; and (iii) notwithstanding any other provision of
17 law, subject to federal approval, on and after July 1, 2012, an
18 increase in the determination of need (DON) scores from 29 to
19 37 for applicants for institutional and home and
20 community-based long term care; if and only if federal
21 approval is not granted, the Department may, in conjunction
22 with other affected agencies, implement utilization controls
23 or changes in benefit packages to effectuate a similar savings
24 amount for this population; and (iv) no later than July 1,
25 2013, minimum level of care eligibility criteria for
26 institutional and home and community-based long term care; and
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1 (v) no later than October 1, 2013, establish procedures to
2 permit long term care providers access to eligibility scores
3 for individuals with an admission date who are seeking or
4 receiving services from the long term care provider. In order
5 to select the minimum level of care eligibility criteria, the
6 Governor shall establish a workgroup that includes affected
7 agency representatives and stakeholders representing the
8 institutional and home and community-based long term care
9 interests. This Section shall not restrict the Department from
10 implementing lower level of care eligibility criteria for
11 community-based services in circumstances where federal
12 approval has been granted.
13 The Illinois Department shall develop and operate, in
14 cooperation with other State Departments and agencies and in
15 compliance with applicable federal laws and regulations,
16 appropriate and effective systems of health care evaluation
17 and programs for monitoring of utilization of health care
18 services and facilities, as it affects persons eligible for
19 medical assistance under this Code.
20 The Illinois Department shall report annually to the
21 General Assembly, no later than the second Friday in April of
22 1979 and each year thereafter, in regard to:
23 (a) actual statistics and trends in utilization of
24 medical services by public aid recipients;
25 (b) actual statistics and trends in the provision of
26 the various medical services by medical vendors;
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1 (c) current rate structures and proposed changes in
2 those rate structures for the various medical vendors; and
3 (d) efforts at utilization review and control by the
4 Illinois Department.
5 The period covered by each report shall be the 3 years
6 ending on the June 30 prior to the report. The report shall
7 include suggested legislation for consideration by the General
8 Assembly. The requirement for reporting to the General
9 Assembly shall be satisfied by filing copies of the report as
10 required by Section 3.1 of the General Assembly Organization
11 Act, and filing such additional copies with the State
12 Government Report Distribution Center for the General Assembly
13 as is required under paragraph (t) of Section 7 of the State
14 Library Act.
15 Rulemaking authority to implement Public Act 95-1045, if
16 any, is conditioned on the rules being adopted in accordance
17 with all provisions of the Illinois Administrative Procedure
18 Act and all rules and procedures of the Joint Committee on
19 Administrative Rules; any purported rule not so adopted, for
20 whatever reason, is unauthorized.
21 On and after July 1, 2012, the Department shall reduce any
22 rate of reimbursement for services or other payments or alter
23 any methodologies authorized by this Code to reduce any rate
24 of reimbursement for services or other payments in accordance
25 with Section 5-5e.
26 Because kidney transplantation can be an appropriate,
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1 cost-effective alternative to renal dialysis when medically
2 necessary and notwithstanding the provisions of Section 1-11
3 of this Code, beginning October 1, 2014, the Department shall
4 cover kidney transplantation for noncitizens with end-stage
5 renal disease who are not eligible for comprehensive medical
6 benefits, who meet the residency requirements of Section 5-3
7 of this Code, and who would otherwise meet the financial
8 requirements of the appropriate class of eligible persons
9 under Section 5-2 of this Code. To qualify for coverage of
10 kidney transplantation, such person must be receiving
11 emergency renal dialysis services covered by the Department.
12 Providers under this Section shall be prior approved and
13 certified by the Department to perform kidney transplantation
14 and the services under this Section shall be limited to
15 services associated with kidney transplantation.
16 Notwithstanding any other provision of this Code to the
17 contrary, on or after July 1, 2015, all FDA-approved FDA
18 approved forms of medication assisted treatment prescribed for
19 the treatment of alcohol dependence or treatment of opioid
20 dependence shall be covered under both fee-for-service and
21 managed care medical assistance programs for persons who are
22 otherwise eligible for medical assistance under this Article
23 and shall not be subject to any (1) utilization control, other
24 than those established under the American Society of Addiction
25 Medicine patient placement criteria, (2) prior authorization
26 mandate, (3) lifetime restriction limit mandate, or (4)
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1 limitations on dosage.
2 On or after July 1, 2015, opioid antagonists prescribed
3 for the treatment of an opioid overdose, including the
4 medication product, administration devices, and any pharmacy
5 fees or hospital fees related to the dispensing, distribution,
6 and administration of the opioid antagonist, shall be covered
7 under the medical assistance program for persons who are
8 otherwise eligible for medical assistance under this Article.
9 As used in this Section, "opioid antagonist" means a drug that
10 binds to opioid receptors and blocks or inhibits the effect of
11 opioids acting on those receptors, including, but not limited
12 to, naloxone hydrochloride or any other similarly acting drug
13 approved by the U.S. Food and Drug Administration. The
14 Department shall not impose a copayment on the coverage
15 provided for naloxone hydrochloride under the medical
16 assistance program.
17 Upon federal approval, the Department shall provide
18 coverage and reimbursement for all drugs that are approved for
19 marketing by the federal Food and Drug Administration and that
20 are recommended by the federal Public Health Service or the
21 United States Centers for Disease Control and Prevention for
22 pre-exposure prophylaxis and related pre-exposure prophylaxis
23 services, including, but not limited to, HIV and sexually
24 transmitted infection screening, treatment for sexually
25 transmitted infections, medical monitoring, assorted labs, and
26 counseling to reduce the likelihood of HIV infection among
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1 individuals who are not infected with HIV but who are at high
2 risk of HIV infection.
3 A federally qualified health center, as defined in Section
4 1905(l)(2)(B) of the federal Social Security Act, shall be
5 reimbursed by the Department in accordance with the federally
6 qualified health center's encounter rate for services provided
7 to medical assistance recipients that are performed by a
8 dental hygienist, as defined under the Illinois Dental
9 Practice Act, working under the general supervision of a
10 dentist and employed by a federally qualified health center.
11 Within 90 days after October 8, 2021 (the effective date
12 of Public Act 102-665), the Department shall seek federal
13 approval of a State Plan amendment to expand coverage for
14 family planning services that includes presumptive eligibility
15 to individuals whose income is at or below 208% of the federal
16 poverty level. Coverage under this Section shall be effective
17 beginning no later than December 1, 2022.
18 Subject to approval by the federal Centers for Medicare
19 and Medicaid Services of a Title XIX State Plan amendment
20 electing the Program of All-Inclusive Care for the Elderly
21 (PACE) as a State Medicaid option, as provided for by Subtitle
22 I (commencing with Section 4801) of Title IV of the Balanced
23 Budget Act of 1997 (Public Law 105-33) and Part 460
24 (commencing with Section 460.2) of Subchapter E of Title 42 of
25 the Code of Federal Regulations, PACE program services shall
26 become a covered benefit of the medical assistance program,
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1 subject to criteria established in accordance with all
2 applicable laws.
3 Notwithstanding any other provision of this Code,
4 community-based pediatric palliative care from a trained
5 interdisciplinary team shall be covered under the medical
6 assistance program as provided in Section 15 of the Pediatric
7 Palliative Care Act.
8 Notwithstanding any other provision of this Code, within
9 12 months after June 2, 2022 (the effective date of Public Act
10 102-1037) and subject to federal approval, acupuncture
11 services performed by an acupuncturist licensed under the
12 Acupuncture Practice Act who is acting within the scope of his
13 or her license shall be covered under the medical assistance
14 program. The Department shall apply for any federal waiver or
15 State Plan amendment, if required, to implement this
16 paragraph. The Department may adopt any rules, including
17 standards and criteria, necessary to implement this paragraph.
18 Notwithstanding any other provision of this Code, the
19 medical assistance program shall, subject to federal approval,
20 reimburse hospitals for costs associated with a newborn
21 screening test for the presence of metachromatic
22 leukodystrophy, as required under the Newborn Metabolic
23 Screening Act, at a rate not less than the fee charged by the
24 Department of Public Health. Notwithstanding any other
25 provision of this Code, the medical assistance program shall,
26 subject to appropriation and federal approval, also reimburse
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1 hospitals for costs associated with all newborn screening
2 tests added on and after August 9, 2024 (the effective date of
3 Public Act 103-909) this amendatory Act of the 103rd General
4 Assembly to the Newborn Metabolic Screening Act and required
5 to be performed under that Act at a rate not less than the fee
6 charged by the Department of Public Health. The Department
7 shall seek federal approval before the implementation of the
8 newborn screening test fees by the Department of Public
9 Health.
10 Notwithstanding any other provision of this Code,
11 beginning on January 1, 2024, subject to federal approval,
12 cognitive assessment and care planning services provided to a
13 person who experiences signs or symptoms of cognitive
14 impairment, as defined by the Diagnostic and Statistical
15 Manual of Mental Disorders, Fifth Edition, shall be covered
16 under the medical assistance program for persons who are
17 otherwise eligible for medical assistance under this Article.
18 Notwithstanding any other provision of this Code,
19 medically necessary reconstructive services that are intended
20 to restore physical appearance shall be covered under the
21 medical assistance program for persons who are otherwise
22 eligible for medical assistance under this Article. As used in
23 this paragraph, "reconstructive services" means treatments
24 performed on structures of the body damaged by trauma to
25 restore physical appearance.
26 Subject to federal approval, for dates of services on and
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1 after January 1, 2026, over-the-counter choline dietary
2 supplements for pregnant persons shall be covered under the
3 medical assistance program.
4 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
5 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
6 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
7 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
8 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
9 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
10 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
11 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
12 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
13 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
14 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
15 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
16 8-9-24; revised 10-10-24.)
17 ARTICLE 45.
18 Section 45-5. The Illinois Public Aid Code is amended by
19 changing Section 11-4 as follows:
20 (305 ILCS 5/11-4) (from Ch. 23, par. 11-4)
21 Sec. 11-4. Applications; assistance in making
22 applications. An initial application for public assistance
23 shall be deemed an application for all such benefits to which
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1 any person may be entitled except to the extent that the
2 applicant expressly declines in writing to apply for
3 particular benefits. The redetermination is an annual
4 redetermination of eligibility of current benefits and is not
5 an initial application. The Illinois Department shall provide
6 information in writing about all benefits provided under this
7 Code to any person seeking public assistance. The Illinois
8 Department shall also provide information in writing and
9 orally to all applicants about an election to have financial
10 aid deposited directly in a recipient's savings account or
11 checking account or in any electronic benefits account or
12 accounts as provided in Section 11-3.1, to the extent that
13 those elections are actually available, including information
14 on any programs administered by the State Treasurer to
15 facilitate or encourage the distribution of financial aid by
16 direct deposit or electronic benefits transfer. The Illinois
17 Department shall determine the applicant's eligibility for
18 cash assistance, medical assistance and food stamps unless the
19 applicant expressly declines in writing to apply for
20 particular benefits. The Illinois Department shall adopt
21 policies and procedures to facilitate timely changes between
22 programs that result from changes in categorical eligibility
23 factors.
24 The County departments, local governmental units and the
25 Illinois Department shall assist applicants for public
26 assistance to properly complete their applications. Such
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1 assistance shall include, but not be limited to, assistance in
2 securing evidence in support of their eligibility.
3 (Source: P.A. 88-232.)
4 ARTICLE 66.
5 Section 66-5. The Illinois Public Aid Code is amended by
6 changing Section 14-12 as follows:
7 (305 ILCS 5/14-12)
8 Sec. 14-12. Hospital rate reform payment system. The
9 hospital payment system pursuant to Section 14-11 of this
10 Article shall be as follows:
11 (a) Inpatient hospital services. Effective for discharges
12 on and after the effective date of this amendatory Act of the
13 104th General Assembly July 1, 2014, reimbursement for
14 inpatient general acute care services shall utilize the All
15 Patient Refined Diagnosis Related Grouping (APR-DRG) software,
16 version 30, distributed by SolventumTM previously known as 3MTM
17 Health Information System. SolventumTM shall be the exclusive
18 provider of this software unless the Department determines
19 that SolventumTM is unable to meet the required operational or
20 contractual terms. Only under these circumstances may an
21 alternative authorized provider of the software be considered.
22 (1) The Department shall establish Medicaid weighting
23 factors to be used in the reimbursement system established
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1 under this subsection. Initial weighting factors shall be
2 the weighting factors as published by the authorized
3 provider of this software 3M Health Information System,
4 associated with Version 30.0 adjusted for the Illinois
5 experience.
6 (2) The Department shall establish a
7 statewide-standardized amount to be used in the inpatient
8 reimbursement system. The Department shall publish these
9 amounts on its website no later than 10 calendar days
10 prior to their effective date.
11 (3) In addition to the statewide-standardized amount,
12 the Department shall develop adjusters to adjust the rate
13 of reimbursement for critical Medicaid providers or
14 services for trauma, transplantation services, perinatal
15 care, and Graduate Medical Education (GME).
16 (4) The Department shall develop add-on payments to
17 account for exceptionally costly inpatient stays,
18 consistent with Medicare outlier principles. Outlier fixed
19 loss thresholds may be updated to control for excessive
20 growth in outlier payments no more frequently than on an
21 annual basis, but at least once every 4 years. Upon
22 updating the fixed loss thresholds, the Department shall
23 be required to update base rates within 12 months.
24 (5) The Department shall define those hospitals or
25 distinct parts of hospitals that shall be exempt from the
26 APR-DRG reimbursement system established under this
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1 Section. The Department shall publish these hospitals'
2 inpatient rates on its website no later than 10 calendar
3 days prior to their effective date.
4 (6) Beginning July 1, 2014 and ending on December 31,
5 2023, in addition to the statewide-standardized amount,
6 the Department shall develop an adjustor to adjust the
7 rate of reimbursement for safety-net hospitals defined in
8 Section 5-5e.1 of this Code excluding pediatric hospitals.
9 (7) Beginning July 1, 2014, in addition to the
10 statewide-standardized amount, the Department shall
11 develop an adjustor to adjust the rate of reimbursement
12 for Illinois freestanding inpatient psychiatric hospitals
13 that are not designated as children's hospitals by the
14 Department but are primarily treating patients under the
15 age of 21.
16 (7.5) (Blank).
17 (8) Beginning July 1, 2018, in addition to the
18 statewide-standardized amount, the Department shall adjust
19 the rate of reimbursement for hospitals designated by the
20 Department of Public Health as a Perinatal Level II or II+
21 center by applying the same adjustor that is applied to
22 Perinatal and Obstetrical care cases for Perinatal Level
23 III centers, as of December 31, 2017.
24 (9) Beginning July 1, 2018, in addition to the
25 statewide-standardized amount, the Department shall apply
26 the same adjustor that is applied to trauma cases as of
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1 December 31, 2017 to inpatient claims to treat patients
2 with burns, including, but not limited to, APR-DRGs 841,
3 842, 843, and 844.
4 (10) Beginning July 1, 2018, the
5 statewide-standardized amount for inpatient general acute
6 care services shall be uniformly increased so that base
7 claims projected reimbursement is increased by an amount
8 equal to the funds allocated in paragraph (1) of
9 subsection (b) of Section 5A-12.6, less the amount
10 allocated under paragraphs (8) and (9) of this subsection
11 and paragraphs (3) and (4) of subsection (b) multiplied by
12 40%.
13 (11) Beginning July 1, 2018, the reimbursement for
14 inpatient rehabilitation services shall be increased by
15 the addition of a $96 per day add-on.
16 (b) Outpatient hospital services. Effective on and after
17 the effective date of this amendatory Act of the 104th General
18 Assembly, for dates of service on and after July 1, 2014,
19 reimbursement for outpatient services shall utilize the
20 Enhanced Ambulatory Procedure Grouping (EAPG) software,
21 version 3.7 distributed by SolventumTM previously known as 3MTM
22 Health Information System. SolventumTM shall be the exclusive
23 provider of this software unless the Agency determines that
24 SolventumTM is unable to meet the required operational or
25 contractual terms. Only under these circumstances may an
26 alternative authorized provider of the software be considered.
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1 (1) The Department shall establish Medicaid weighting
2 factors to be used in the reimbursement system established
3 under this subsection. The initial weighting factors shall
4 be the weighting factors as published by the authorized
5 provider 3M Health Information System, associated with
6 Version 3.7.
7 (2) The Department shall establish service specific
8 statewide-standardized amounts to be used in the
9 reimbursement system.
10 (A) The initial statewide standardized amounts,
11 with the labor portion adjusted by the Calendar Year
12 2013 Medicare Outpatient Prospective Payment System
13 wage index with reclassifications, shall be published
14 by the Department on its website no later than 10
15 calendar days prior to their effective date.
16 (B) The Department shall establish adjustments to
17 the statewide-standardized amounts for each Critical
18 Access Hospital, as designated by the Department of
19 Public Health in accordance with 42 CFR 485, Subpart
20 F. For outpatient services provided on or before June
21 30, 2018, the EAPG standardized amounts are determined
22 separately for each critical access hospital such that
23 simulated EAPG payments using outpatient base period
24 paid claim data plus payments under Section 5A-12.4 of
25 this Code net of the associated tax costs are equal to
26 the estimated costs of outpatient base period claims
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1 data with a rate year cost inflation factor applied.
2 (3) In addition to the statewide-standardized amounts,
3 the Department shall develop adjusters to adjust the rate
4 of reimbursement for critical Medicaid hospital outpatient
5 providers or services, including outpatient high volume or
6 safety-net hospitals. Beginning July 1, 2018, the
7 outpatient high volume adjustor shall be increased to
8 increase annual expenditures associated with this adjustor
9 by $79,200,000, based on the State Fiscal Year 2015 base
10 year data and this adjustor shall apply to public
11 hospitals, except for large public hospitals, as defined
12 under 89 Ill. Adm. Code 148.25(a).
13 (4) Beginning July 1, 2018, in addition to the
14 statewide standardized amounts, the Department shall make
15 an add-on payment for outpatient expensive devices and
16 drugs. This add-on payment shall at least apply to claim
17 lines that: (i) are assigned with one of the following
18 EAPGs: 490, 1001 to 1020, and coded with one of the
19 following revenue codes: 0274 to 0276, 0278; or (ii) are
20 assigned with one of the following EAPGs: 430 to 441, 443,
21 444, 460 to 465, 495, 496, 1090. The add-on payment shall
22 be calculated as follows: the claim line's covered charges
23 multiplied by the hospital's total acute cost to charge
24 ratio, less the claim line's EAPG payment plus $1,000,
25 multiplied by 0.8.
26 (5) Beginning July 1, 2018, the statewide-standardized
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1 amounts for outpatient services shall be increased by a
2 uniform percentage so that base claims projected
3 reimbursement is increased by an amount equal to no less
4 than the funds allocated in paragraph (1) of subsection
5 (b) of Section 5A-12.6, less the amount allocated under
6 paragraphs (8) and (9) of subsection (a) and paragraphs
7 (3) and (4) of this subsection multiplied by 46%.
8 (6) Effective for dates of service on or after July 1,
9 2018, the Department shall establish adjustments to the
10 statewide-standardized amounts for each Critical Access
11 Hospital, as designated by the Department of Public Health
12 in accordance with 42 CFR 485, Subpart F, such that each
13 Critical Access Hospital's standardized amount for
14 outpatient services shall be increased by the applicable
15 uniform percentage determined pursuant to paragraph (5) of
16 this subsection. It is the intent of the General Assembly
17 that the adjustments required under this paragraph (6) by
18 Public Act 100-1181 shall be applied retroactively to
19 claims for dates of service provided on or after July 1,
20 2018.
21 (7) Effective for dates of service on or after March
22 8, 2019 (the effective date of Public Act 100-1181), the
23 Department shall recalculate and implement an updated
24 statewide-standardized amount for outpatient services
25 provided by hospitals that are not Critical Access
26 Hospitals to reflect the applicable uniform percentage
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1 determined pursuant to paragraph (5).
2 (1) Any recalculation to the
3 statewide-standardized amounts for outpatient services
4 provided by hospitals that are not Critical Access
5 Hospitals shall be the amount necessary to achieve the
6 increase in the statewide-standardized amounts for
7 outpatient services increased by a uniform percentage,
8 so that base claims projected reimbursement is
9 increased by an amount equal to no less than the funds
10 allocated in paragraph (1) of subsection (b) of
11 Section 5A-12.6, less the amount allocated under
12 paragraphs (8) and (9) of subsection (a) and
13 paragraphs (3) and (4) of this subsection, for all
14 hospitals that are not Critical Access Hospitals,
15 multiplied by 46%.
16 (2) It is the intent of the General Assembly that
17 the recalculations required under this paragraph (7)
18 by Public Act 100-1181 shall be applied prospectively
19 to claims for dates of service provided on or after
20 March 8, 2019 (the effective date of Public Act
21 100-1181) and that no recoupment or repayment by the
22 Department or an MCO of payments attributable to
23 recalculation under this paragraph (7), issued to the
24 hospital for dates of service on or after July 1, 2018
25 and before March 8, 2019 (the effective date of Public
26 Act 100-1181), shall be permitted.
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1 (8) The Department shall ensure that all necessary
2 adjustments to the managed care organization capitation
3 base rates necessitated by the adjustments under
4 subparagraph (6) or (7) of this subsection are completed
5 and applied retroactively in accordance with Section
6 5-30.8 of this Code within 90 days of March 8, 2019 (the
7 effective date of Public Act 100-1181).
8 (9) Within 60 days after federal approval of the
9 change made to the assessment in Section 5A-2 by Public
10 Act 101-650, the Department shall incorporate into the
11 EAPG system for outpatient services those services
12 performed by hospitals currently billed through the
13 Non-Institutional Provider billing system.
14 (b-5) Notwithstanding any other provision of this Section,
15 beginning with dates of service on and after January 1, 2023,
16 any general acute care hospital with more than 500 outpatient
17 psychiatric Medicaid services to persons under 19 years of age
18 in any calendar year shall be paid the outpatient add-on
19 payment of no less than $113.
20 (c) In consultation with the hospital community, the
21 Department is authorized to replace 89 Ill. Adm. Code 152.150
22 as published in 38 Ill. Reg. 4980 through 4986 within 12 months
23 of June 16, 2014 (the effective date of Public Act 98-651). If
24 the Department does not replace these rules within 12 months
25 of June 16, 2014 (the effective date of Public Act 98-651), the
26 rules in effect for 152.150 as published in 38 Ill. Reg. 4980
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1 through 4986 shall remain in effect until modified by rule by
2 the Department. Nothing in this subsection shall be construed
3 to mandate that the Department file a replacement rule.
4 (d) Transition period. There shall be a transition period
5 to the reimbursement systems authorized under this Section
6 that shall begin on the effective date of these systems and
7 continue until June 30, 2018, unless extended by rule by the
8 Department. To help provide an orderly and predictable
9 transition to the new reimbursement systems and to preserve
10 and enhance access to the hospital services during this
11 transition, the Department shall allocate a transitional
12 hospital access pool of at least $290,000,000 annually so that
13 transitional hospital access payments are made to hospitals.
14 (1) After the transition period, the Department may
15 begin incorporating the transitional hospital access pool
16 into the base rate structure; however, the transitional
17 hospital access payments in effect on June 30, 2018 shall
18 continue to be paid, if continued under Section 5A-16.
19 (2) After the transition period, if the Department
20 reduces payments from the transitional hospital access
21 pool, it shall increase base rates, develop new adjustors,
22 adjust current adjustors, develop new hospital access
23 payments based on updated information, or any combination
24 thereof by an amount equal to the decreases proposed in
25 the transitional hospital access pool payments, ensuring
26 that the entire transitional hospital access pool amount
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1 shall continue to be used for hospital payments.
2 (d-5) Hospital and health care transformation program. The
3 Department shall develop a hospital and health care
4 transformation program to provide financial assistance to
5 hospitals in transforming their services and care models to
6 better align with the needs of the communities they serve. The
7 payments authorized in this Section shall be subject to
8 approval by the federal government.
9 (1) Phase 1. In State fiscal years 2019 through 2020,
10 the Department shall allocate funds from the transitional
11 access hospital pool to create a hospital transformation
12 pool of at least $262,906,870 annually and make hospital
13 transformation payments to hospitals. Subject to Section
14 5A-16, in State fiscal years 2019 and 2020, an Illinois
15 hospital that received either a transitional hospital
16 access payment under subsection (d) or a supplemental
17 payment under subsection (f) of this Section in State
18 fiscal year 2018, shall receive a hospital transformation
19 payment as follows:
20 (A) If the hospital's Rate Year 2017 Medicaid
21 inpatient utilization rate is equal to or greater than
22 45%, the hospital transformation payment shall be
23 equal to 100% of the sum of its transitional hospital
24 access payment authorized under subsection (d) and any
25 supplemental payment authorized under subsection (f).
26 (B) If the hospital's Rate Year 2017 Medicaid
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1 inpatient utilization rate is equal to or greater than
2 25% but less than 45%, the hospital transformation
3 payment shall be equal to 75% of the sum of its
4 transitional hospital access payment authorized under
5 subsection (d) and any supplemental payment authorized
6 under subsection (f).
7 (C) If the hospital's Rate Year 2017 Medicaid
8 inpatient utilization rate is less than 25%, the
9 hospital transformation payment shall be equal to 50%
10 of the sum of its transitional hospital access payment
11 authorized under subsection (d) and any supplemental
12 payment authorized under subsection (f).
13 (2) Phase 2.
14 (A) The funding amount from phase one shall be
15 incorporated into directed payment and pass-through
16 payment methodologies described in Section 5A-12.7.
17 (B) Because there are communities in Illinois that
18 experience significant health care disparities due to
19 systemic racism, as recently emphasized by the
20 COVID-19 pandemic, aggravated by social determinants
21 of health and a lack of sufficiently allocated health
22 care healthcare resources, particularly
23 community-based services, preventive care, obstetric
24 care, chronic disease management, and specialty care,
25 the Department shall establish a health care
26 transformation program that shall be supported by the
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1 transformation funding pool. It is the intention of
2 the General Assembly that innovative partnerships
3 funded by the pool must be designed to establish or
4 improve integrated health care delivery systems that
5 will provide significant access to the Medicaid and
6 uninsured populations in their communities, as well as
7 improve health care equity. It is also the intention
8 of the General Assembly that partnerships recognize
9 and address the disparities revealed by the COVID-19
10 pandemic, as well as the need for post-COVID care.
11 During State fiscal years 2021 through 2027, the
12 hospital and health care transformation program shall
13 be supported by an annual transformation funding pool
14 of up to $150,000,000, pending federal matching funds,
15 to be allocated during the specified fiscal years for
16 the purpose of facilitating hospital and health care
17 transformation. No disbursement of moneys for
18 transformation projects from the transformation
19 funding pool described under this Section shall be
20 considered an award, a grant, or an expenditure of
21 grant funds. Funding agreements made in accordance
22 with the transformation program shall be considered
23 purchases of care under the Illinois Procurement Code,
24 and funds shall be expended by the Department in a
25 manner that maximizes federal funding to expend the
26 entire allocated amount.
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1 The Department shall convene, within 30 days after
2 March 12, 2021 (the effective date of Public Act
3 101-655), a workgroup that includes subject matter
4 experts on health care healthcare disparities and
5 stakeholders from distressed communities, which could
6 be a subcommittee of the Medicaid Advisory Committee,
7 to review and provide recommendations on how
8 Department policy, including health care
9 transformation, can improve health disparities and the
10 impact on communities disproportionately affected by
11 COVID-19. The workgroup shall consider and make
12 recommendations on the following issues: a community
13 safety-net designation of certain hospitals, racial
14 equity, and a regional partnership to bring additional
15 specialty services to communities.
16 (C) As provided in paragraph (9) of Section 3 of
17 the Illinois Health Facilities Planning Act, any
18 hospital participating in the transformation program
19 may be excluded from the requirements of the Illinois
20 Health Facilities Planning Act for those projects
21 related to the hospital's transformation. To be
22 eligible, the hospital must submit to the Health
23 Facilities and Services Review Board approval from the
24 Department that the project is a part of the
25 hospital's transformation.
26 (D) As provided in subsection (a-20) of Section
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1 32.5 of the Emergency Medical Services (EMS) Systems
2 Act, a hospital that received hospital transformation
3 payments under this Section may convert to a
4 freestanding emergency center. To be eligible for such
5 a conversion, the hospital must submit to the
6 Department of Public Health approval from the
7 Department that the project is a part of the
8 hospital's transformation.
9 (E) Criteria for proposals. To be eligible for
10 funding under this Section, a transformation proposal
11 shall meet all of the following criteria:
12 (i) the proposal shall be designed based on
13 community needs assessment completed by either a
14 University partner or other qualified entity with
15 significant community input;
16 (ii) the proposal shall be a collaboration
17 among providers across the care and community
18 spectrum, including preventative care, primary
19 care specialty care, hospital services, mental
20 health and substance abuse services, as well as
21 community-based entities that address the social
22 determinants of health;
23 (iii) the proposal shall be specifically
24 designed to improve health care healthcare
25 outcomes and reduce health care healthcare
26 disparities, and improve the coordination,
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1 effectiveness, and efficiency of care delivery;
2 (iv) the proposal shall have specific
3 measurable metrics related to disparities that
4 will be tracked by the Department and made public
5 by the Department;
6 (v) the proposal shall include a commitment to
7 include Business Enterprise Program certified
8 vendors or other entities controlled and managed
9 by minorities or women; and
10 (vi) the proposal shall specifically increase
11 access to primary, preventive, or specialty care.
12 (F) Entities eligible to be funded.
13 (i) Proposals for funding should come from
14 collaborations operating in one of the most
15 distressed communities in Illinois as determined
16 by the U.S. Centers for Disease Control and
17 Prevention's Social Vulnerability Index for
18 Illinois and areas disproportionately impacted by
19 COVID-19 or from rural areas of Illinois.
20 (ii) The Department shall prioritize
21 partnerships from distressed communities, which
22 include Business Enterprise Program certified
23 vendors or other entities controlled and managed
24 by minorities or women and also include one or
25 more of the following: safety-net hospitals,
26 critical access hospitals, the campuses of
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1 hospitals that have closed since January 1, 2018,
2 or other health care healthcare providers designed
3 to address specific health care healthcare
4 disparities, including the impact of COVID-19 on
5 individuals and the community and the need for
6 post-COVID care. All funded proposals must include
7 specific measurable goals and metrics related to
8 improved outcomes and reduced disparities which
9 shall be tracked by the Department.
10 (iii) The Department should target the funding
11 in the following ways: $30,000,000 of
12 transformation funds to projects that are a
13 collaboration between a safety-net hospital,
14 particularly community safety-net hospitals, and
15 other providers and designed to address specific
16 health care healthcare disparities, $20,000,000 of
17 transformation funds to collaborations between
18 safety-net hospitals and a larger hospital partner
19 that increases specialty care in distressed
20 communities, $30,000,000 of transformation funds
21 to projects that are a collaboration between
22 hospitals and other providers in distressed areas
23 of the State designed to address specific health
24 care healthcare disparities, $15,000,000 to
25 collaborations between critical access hospitals
26 and other providers designed to address specific
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1 health care healthcare disparities, and
2 $15,000,000 to cross-provider collaborations
3 designed to address specific health care
4 healthcare disparities, and $5,000,000 to
5 collaborations that focus on workforce
6 development.
7 (iv) The Department may allocate up to
8 $5,000,000 for planning, racial equity analysis,
9 or consulting resources for the Department or
10 entities without the resources to develop a plan
11 to meet the criteria of this Section. Any contract
12 for consulting services issued by the Department
13 under this subparagraph shall comply with the
14 provisions of Section 5-45 of the State Officials
15 and Employees Ethics Act. Based on availability of
16 federal funding, the Department may directly
17 procure consulting services or provide funding to
18 the collaboration. The provision of resources
19 under this subparagraph is not a guarantee that a
20 project will be approved.
21 (v) The Department shall take steps to ensure
22 that safety-net hospitals operating in
23 under-resourced communities receive priority
24 access to hospital and health care healthcare
25 transformation funds, including consulting funds,
26 as provided under this Section.
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1 (G) Process for submitting and approving projects
2 for distressed communities. The Department shall issue
3 a template for application. The Department shall post
4 any proposal received on the Department's website for
5 at least 2 weeks for public comment, and any such
6 public comment shall also be considered in the review
7 process. Applicants may request that proprietary
8 financial information be redacted from publicly posted
9 proposals and the Department in its discretion may
10 agree. Proposals for each distressed community must
11 include all of the following:
12 (i) A detailed description of how the project
13 intends to affect the goals outlined in this
14 subsection, describing new interventions, new
15 technology, new structures, and other changes to
16 the health care healthcare delivery system
17 planned.
18 (ii) A detailed description of the racial and
19 ethnic makeup of the entities' board and
20 leadership positions and the salaries of the
21 executive staff of entities in the partnership
22 that is seeking to obtain funding under this
23 Section.
24 (iii) A complete budget, including an overall
25 timeline and a detailed pathway to sustainability
26 within a 5-year period, specifying other sources
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1 of funding, such as in-kind, cost-sharing, or
2 private donations, particularly for capital needs.
3 There is an expectation that parties to the
4 transformation project dedicate resources to the
5 extent they are able and that these expectations
6 are delineated separately for each entity in the
7 proposal.
8 (iv) A description of any new entities formed
9 or other legal relationships between collaborating
10 entities and how funds will be allocated among
11 participants.
12 (v) A timeline showing the evolution of sites
13 and specific services of the project over a 5-year
14 period, including services available to the
15 community by site.
16 (vi) Clear milestones indicating progress
17 toward the proposed goals of the proposal as
18 checkpoints along the way to continue receiving
19 funding. The Department is authorized to refine
20 these milestones in agreements, and is authorized
21 to impose reasonable penalties, including
22 repayment of funds, for substantial lack of
23 progress.
24 (vii) A clear statement of the level of
25 commitment the project will include for minorities
26 and women in contracting opportunities, including
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1 as equity partners where applicable, or as
2 subcontractors and suppliers in all phases of the
3 project.
4 (viii) If the community study utilized is not
5 the study commissioned and published by the
6 Department, the applicant must define the
7 methodology used, including documentation of clear
8 community participation.
9 (ix) A description of the process used in
10 collaborating with all levels of government in the
11 community served in the development of the
12 project, including, but not limited to,
13 legislators and officials of other units of local
14 government.
15 (x) Documentation of a community input process
16 in the community served, including links to
17 proposal materials on public websites.
18 (xi) Verifiable project milestones and quality
19 metrics that will be impacted by transformation.
20 These project milestones and quality metrics must
21 be identified with improvement targets that must
22 be met.
23 (xii) Data on the number of existing employees
24 by various job categories and wage levels by the
25 zip code of the employees' residence and
26 benchmarks for the continued maintenance and
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1 improvement of these levels. The proposal must
2 also describe any retraining or other workforce
3 development planned for the new project.
4 (xiii) If a new entity is created by the
5 project, a description of how the board will be
6 reflective of the community served by the
7 proposal.
8 (xiv) An explanation of how the proposal will
9 address the existing disparities that exacerbated
10 the impact of COVID-19 and the need for post-COVID
11 care in the community, if applicable.
12 (xv) An explanation of how the proposal is
13 designed to increase access to care, including
14 specialty care based upon the community's needs.
15 (H) The Department shall evaluate proposals for
16 compliance with the criteria listed under subparagraph
17 (G). Proposals meeting all of the criteria may be
18 eligible for funding with the areas of focus
19 prioritized as described in item (ii) of subparagraph
20 (F). Based on the funds available, the Department may
21 negotiate funding agreements with approved applicants
22 to maximize federal funding. Nothing in this
23 subsection requires that an approved project be funded
24 to the level requested. Agreements shall specify the
25 amount of funding anticipated annually, the
26 methodology of payments, the limit on the number of
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1 years such funding may be provided, and the milestones
2 and quality metrics that must be met by the projects in
3 order to continue to receive funding during each year
4 of the program. Agreements shall specify the terms and
5 conditions under which a health care facility that
6 receives funds under a purchase of care agreement and
7 closes in violation of the terms of the agreement must
8 pay an early closure fee no greater than 50% of the
9 funds it received under the agreement, prior to the
10 Health Facilities and Services Review Board
11 considering an application for closure of the
12 facility. Any project that is funded shall be required
13 to provide quarterly written progress reports, in a
14 form prescribed by the Department, and at a minimum
15 shall include the progress made in achieving any
16 milestones or metrics or Business Enterprise Program
17 commitments in its plan. The Department may reduce or
18 end payments, as set forth in transformation plans, if
19 milestones or metrics or Business Enterprise Program
20 commitments are not achieved. The Department shall
21 seek to make payments from the transformation fund in
22 a manner that is eligible for federal matching funds.
23 In reviewing the proposals, the Department shall
24 take into account the needs of the community, data
25 from the study commissioned by the Department from the
26 University of Illinois-Chicago if applicable, feedback
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1 from public comment on the Department's website, as
2 well as how the proposal meets the criteria listed
3 under subparagraph (G). Alignment with the
4 Department's overall strategic initiatives shall be an
5 important factor. To the extent that fiscal year
6 funding is not adequate to fund all eligible projects
7 that apply, the Department shall prioritize
8 applications that most comprehensively and effectively
9 address the criteria listed under subparagraph (G).
10 (3) (Blank).
11 (4) Hospital Transformation Review Committee. There is
12 created the Hospital Transformation Review Committee. The
13 Committee shall consist of 14 members. No later than 30
14 days after March 12, 2018 (the effective date of Public
15 Act 100-581), the 4 legislative leaders shall each appoint
16 3 members; the Governor shall appoint the Director of
17 Healthcare and Family Services, or his or her designee, as
18 a member; and the Director of Healthcare and Family
19 Services shall appoint one member. Any vacancy shall be
20 filled by the applicable appointing authority within 15
21 calendar days. The members of the Committee shall select a
22 Chair and a Vice-Chair from among its members, provided
23 that the Chair and Vice-Chair cannot be appointed by the
24 same appointing authority and must be from different
25 political parties. The Chair shall have the authority to
26 establish a meeting schedule and convene meetings of the
SB2437 Enrolled - 156 - LRB104 10548 KTG 20624 b
1 Committee, and the Vice-Chair shall have the authority to
2 convene meetings in the absence of the Chair. The
3 Committee may establish its own rules with respect to
4 meeting schedule, notice of meetings, and the disclosure
5 of documents; however, the Committee shall not have the
6 power to subpoena individuals or documents and any rules
7 must be approved by 9 of the 14 members. The Committee
8 shall perform the functions described in this Section and
9 advise and consult with the Director in the administration
10 of this Section. In addition to reviewing and approving
11 the policies, procedures, and rules for the hospital and
12 health care transformation program, the Committee shall
13 consider and make recommendations related to qualifying
14 criteria and payment methodologies related to safety-net
15 hospitals and children's hospitals. Members of the
16 Committee appointed by the legislative leaders shall be
17 subject to the jurisdiction of the Legislative Ethics
18 Commission, not the Executive Ethics Commission, and all
19 requests under the Freedom of Information Act shall be
20 directed to the applicable Freedom of Information officer
21 for the General Assembly. The Department shall provide
22 operational support to the Committee as necessary. The
23 Committee is dissolved on April 1, 2019.
24 (e) Beginning 36 months after initial implementation, the
25 Department shall update the reimbursement components in
26 subsections (a) and (b), including standardized amounts and
SB2437 Enrolled - 157 - LRB104 10548 KTG 20624 b
1 weighting factors, and at least once every 4 years and no more
2 frequently than annually thereafter. The Department shall
3 publish these updates on its website no later than 30 calendar
4 days prior to their effective date.
5 (f) Continuation of supplemental payments. Any
6 supplemental payments authorized under 89 Illinois
7 Administrative Code 148 effective January 1, 2014 and that
8 continue during the period of July 1, 2014 through December
9 31, 2014 shall remain in effect as long as the assessment
10 imposed by Section 5A-2 that is in effect on December 31, 2017
11 remains in effect.
12 (g) Notwithstanding subsections (a) through (f) of this
13 Section and notwithstanding the changes authorized under
14 Section 5-5b.1, any updates to the system shall not result in
15 any diminishment of the overall effective rates of
16 reimbursement as of the implementation date of the new system
17 (July 1, 2014). These updates shall not preclude variations in
18 any individual component of the system or hospital rate
19 variations. Nothing in this Section shall prohibit the
20 Department from increasing the rates of reimbursement or
21 developing payments to ensure access to hospital services.
22 Nothing in this Section shall be construed to guarantee a
23 minimum amount of spending in the aggregate or per hospital as
24 spending may be impacted by factors, including, but not
25 limited to, the number of individuals in the medical
26 assistance program and the severity of illness of the
SB2437 Enrolled - 158 - LRB104 10548 KTG 20624 b
1 individuals.
2 (h) The Department shall have the authority to modify by
3 rulemaking any changes to the rates or methodologies in this
4 Section as required by the federal government to obtain
5 federal financial participation for expenditures made under
6 this Section.
7 (i) Except for subsections (g) and (h) of this Section,
8 the Department shall, pursuant to subsection (c) of Section
9 5-40 of the Illinois Administrative Procedure Act, provide for
10 presentation at the June 2014 hearing of the Joint Committee
11 on Administrative Rules (JCAR) additional written notice to
12 JCAR of the following rules in order to commence the second
13 notice period for the following rules: rules published in the
14 Illinois Register, rule dated February 21, 2014 at 38 Ill.
15 Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
16 Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
17 Related Grouping (DRG) Prospective Payment System (PPS)), and
18 4977 (Hospital Reimbursement Changes), and published in the
19 Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
20 (Specialized Health Care Delivery Systems) and 6505 (Hospital
21 Services).
22 (j) Out-of-state hospitals. Beginning July 1, 2018, for
23 purposes of determining for State fiscal years 2019 and 2020
24 and subsequent fiscal years the hospitals eligible for the
25 payments authorized under subsections (a) and (b) of this
26 Section, the Department shall include out-of-state hospitals
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1 that are designated a Level I pediatric trauma center or a
2 Level I trauma center by the Department of Public Health as of
3 December 1, 2017.
4 (k) The Department shall notify each hospital and managed
5 care organization, in writing, of the impact of the updates
6 under this Section at least 30 calendar days prior to their
7 effective date.
8 (l) This Section is subject to Section 14-12.5.
9 (Source: P.A. 102-682, eff. 12-10-21; 102-1037, eff. 6-2-22;
10 103-102, eff. 6-16-23; 103-154, eff. 6-30-23; revised
11 10-16-24.)
12 ARTICLE 67.
13 Section 67-5. The Illinois Public Aid Code is amended by
14 adding Section 10-3.5 as follows:
15 (305 ILCS 5/10-3.5 new)
16 Sec. 10-3.5. Connecting parents to available resources.
17 Beginning July 1, 2025, subject to appropriation and the
18 availability of federal matching funds for the costs to the
19 Department of Healthcare and Family Services for the
20 implementation of this Section, the Illinois Department shall
21 enter into agreements with other State agencies, including,
22 but not limited to, the Department of Employment Security and
23 the Department of Central Management Services, to implement a
SB2437 Enrolled - 160 - LRB104 10548 KTG 20624 b
1 program designed to connect available resources to
2 noncustodial parents whose families are receiving child
3 support enforcement services; who have a child support order
4 or are cooperating to establish a child support order; and who
5 are unemployed or underemployed or at risk of not being able to
6 comply with their support order. The program shall seek to
7 connect parents with resources providing: job search
8 assistance; job readiness training; job development and job
9 placement services; skills assessments to facilitate job
10 placement; job retention services; work supports; and
11 occupational training and other skills training related to
12 employment. The opportunities provided to program participants
13 shall include opportunities offered by employers located in
14 the State, including, but not limited to, State employment.
15 ARTICLE 68.
16 Section 68-3. The Illinois Administrative Procedure Act is
17 amended by adding Section 5-45.65 as follows:
18 (5 ILCS 100/5-45.65 new)
19 Sec. 5-45.65. Emergency rulemaking; Medicaid managed care
20 organization practices. To provide for the expeditious and
21 timely implementation of changes made by this amendatory Act
22 of the 104th General Assembly to subsection (g-13) of Section
23 5-30.1 of the Illinois Public Aid Code, emergency rules
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1 implementing the changes made by this amendatory Act of the
2 104th General Assembly to subsection (g-13) of Section 5-30.1
3 of the Illinois Public Aid Code may be adopted in accordance
4 with Section 5-45 by the Department of Healthcare and Family
5 Services. The adoption of emergency rules authorized by
6 Section 5-45 and this Section is deemed to be necessary for the
7 public interest, safety, and welfare.
8 This Section is repealed one year after the effective date
9 of this amendatory Act of the 104th General Assembly.
10 Section 68-5. The Illinois Public Aid Code is amended by
11 changing Sections 5-30.1 and 5-30.18 as follows:
12 (305 ILCS 5/5-30.1)
13 Sec. 5-30.1. Managed care protections.
14 (a) As used in this Section:
15 "Managed care organization" or "MCO" means any entity
16 which contracts with the Department to provide services where
17 payment for medical services is made on a capitated basis.
18 "Emergency services" means health care items and services,
19 including inpatient and outpatient hospital services,
20 furnished or required to evaluate and stabilize an emergency
21 medical condition. "Emergency services" include inpatient
22 stabilization services furnished during the inpatient
23 stabilization period. "Emergency services" do not include
24 post-stabilization medical services.
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1 "Emergency medical condition" means a medical condition
2 manifesting itself by acute symptoms of sufficient severity,
3 regardless of the final diagnosis given, such that a prudent
4 layperson, who possesses an average knowledge of health and
5 medicine, could reasonably expect the absence of immediate
6 medical attention to result in:
7 (1) placing the health of the individual (or, with
8 respect to a pregnant woman, the health of the woman or her
9 unborn child) in serious jeopardy;
10 (2) serious impairment to bodily functions;
11 (3) serious dysfunction of any bodily organ or part;
12 (4) inadequately controlled pain; or
13 (5) with respect to a pregnant woman who is having
14 contractions:
15 (A) inadequate time to complete a safe transfer to
16 another hospital before delivery; or
17 (B) a transfer to another hospital may pose a
18 threat to the health or safety of the woman or unborn
19 child.
20 "Emergency medical screening examination" means a medical
21 screening examination and evaluation by a physician licensed
22 to practice medicine in all its branches or, to the extent
23 permitted by applicable laws, by other appropriately licensed
24 personnel under the supervision of or in collaboration with a
25 physician licensed to practice medicine in all its branches to
26 determine whether the need for emergency services exists.
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1 "Health care services" mean any medical or behavioral
2 health services covered under the medical assistance program
3 that are subject to review under a service authorization
4 program.
5 "Inpatient stabilization period" means the initial 72
6 hours of inpatient stabilization services, beginning from the
7 date and time of the order for inpatient admission to the
8 hospital.
9 "Inpatient stabilization services" mean emergency services
10 furnished in the inpatient setting at a hospital pursuant to
11 an order for inpatient admission by a physician or other
12 qualified practitioner who has admitting privileges at the
13 hospital, as permitted by State law, to stabilize an emergency
14 medical condition following an emergency medical screening
15 examination.
16 "Post-stabilization medical services" means health care
17 services provided to an enrollee that are furnished in a
18 hospital by a provider that is qualified to furnish such
19 services and determined to be medically necessary by the
20 provider and directly related to the emergency medical
21 condition following stabilization.
22 "Provider" means a facility or individual who is actively
23 enrolled in the medical assistance program and licensed or
24 otherwise authorized to order, prescribe, refer, or render
25 health care services in this State.
26 "Service authorization determination" means a decision
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1 made by a service authorization program in advance of,
2 concurrent to, or after the provision of a health care service
3 to approve, change the level of care, partially deny, deny, or
4 otherwise limit coverage and reimbursement for a health care
5 service upon review of a service authorization request.
6 "Service authorization program" means any utilization
7 review, utilization management, peer review, quality review,
8 or other medical management activity conducted by an MCO, or
9 its contracted utilization review organization, including, but
10 not limited to, prior authorization, prior approval,
11 pre-certification, concurrent review, retrospective review, or
12 certification of admission, of health care services provided
13 in the inpatient or outpatient hospital setting.
14 "Service authorization request" means a request by a
15 provider to a service authorization program to determine
16 whether a health care service meets the reimbursement
17 eligibility requirements for medically necessary, clinically
18 appropriate care, resulting in the issuance of a service
19 authorization determination.
20 "Utilization review organization" or "URO" means an MCO's
21 utilization review department or a peer review organization or
22 quality improvement organization that contracts with an MCO to
23 administer a service authorization program and make service
24 authorization determinations.
25 (b) As provided by Section 5-16.12, managed care
26 organizations are subject to the provisions of the Managed
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1 Care Reform and Patient Rights Act.
2 (c) An MCO shall pay any provider of emergency services,
3 including for inpatient stabilization services provided during
4 the inpatient stabilization period, that does not have in
5 effect a contract with the contracted Medicaid MCO. The
6 default rate of reimbursement shall be the rate paid under
7 Illinois Medicaid fee-for-service program methodology,
8 including all policy adjusters, including but not limited to
9 Medicaid High Volume Adjustments, Medicaid Percentage
10 Adjustments, Outpatient High Volume Adjustments, and all
11 outlier add-on adjustments to the extent such adjustments are
12 incorporated in the development of the applicable MCO
13 capitated rates.
14 (d) (Blank).
15 (e) Notwithstanding any other provision of law, the
16 following requirements apply to MCOs in determining payment
17 for all emergency services, including inpatient stabilization
18 services provided during the inpatient stabilization period:
19 (1) The MCO shall not impose any service authorization
20 program requirements for emergency services, including,
21 but not limited to, prior authorization, prior approval,
22 pre-certification, certification of admission, concurrent
23 review, or retrospective review.
24 (A) Notification period: Hospitals shall notify
25 the enrollee's Medicaid MCO within 48 hours of the
26 date and time the order for inpatient admission is
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1 written. Notification shall be limited to advising the
2 MCO that the patient has been admitted to a hospital
3 inpatient level of care.
4 (B) If the admitting hospital complies with the
5 notification provisions of subparagraph (A), the
6 Medicaid MCO may not initiate concurrent review before
7 the end of the inpatient stabilization period. If the
8 admitting hospital does not comply with the
9 notification requirements in subparagraph (A), the
10 Medicaid MCO may initiate concurrent review for the
11 continuation of the stay beginning at the end of the
12 48-hour notification period.
13 (C) Coverage for services provided during the
14 48-hour notification period may not be retrospectively
15 denied.
16 (2) The MCO shall cover emergency services provided to
17 enrollees who are temporarily away from their residence
18 and outside the contracting area to the extent that the
19 enrollees would be entitled to the emergency services if
20 they still were within the contracting area.
21 (3) The MCO shall have no obligation to cover
22 emergency services provided on an emergency basis that are
23 not covered services under the contract between the MCO
24 and the Department.
25 (4) The MCO shall not condition coverage for emergency
26 services on the treating provider notifying the MCO of the
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1 enrollee's emergency medical screening examination and
2 treatment within 10 days after presentation for emergency
3 services.
4 (5) The determination of the attending emergency
5 physician, or the practitioner responsible for the
6 enrollee's care at the hospital, of whether an enrollee
7 requires inpatient stabilization services, can be
8 stabilized in the outpatient setting, or is sufficiently
9 stabilized for discharge or transfer to another setting,
10 shall be binding on the MCO. The MCO shall cover and
11 reimburse providers for emergency services as billed by
12 the provider for all enrollees whether the emergency
13 services are provided by an affiliated or non-affiliated
14 provider, except in cases of fraud. The MCO shall
15 reimburse inpatient stabilization services provided during
16 the inpatient stabilization period and billed as inpatient
17 level of care based on the appropriate inpatient
18 reimbursement methodology.
19 (6) The MCO's financial responsibility for
20 post-stabilization medical services it has not
21 pre-approved ends when:
22 (A) a plan physician with privileges at the
23 treating hospital assumes responsibility for the
24 enrollee's care;
25 (B) a plan physician assumes responsibility for
26 the enrollee's care through transfer;
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1 (C) a contracting entity representative and the
2 treating physician reach an agreement concerning the
3 enrollee's care; or
4 (D) the enrollee is discharged.
5 (e-5) An MCO shall pay for all post-stabilization medical
6 services as a covered service in any of the following
7 situations:
8 (1) the MCO or its URO authorized such services;
9 (2) such services were administered to maintain the
10 enrollee's stabilized condition within one hour after a
11 request to the MCO for authorization of further
12 post-stabilization services;
13 (3) the MCO or its URO did not respond to a request to
14 authorize such services within one hour;
15 (4) the MCO or its URO could not be contacted; or
16 (5) the MCO or its URO and the treating provider, if
17 the treating provider is a non-affiliated provider, could
18 not reach an agreement concerning the enrollee's care and
19 an affiliated provider was unavailable for a consultation,
20 in which case the MCO must pay for such services rendered
21 by the treating non-affiliated provider until an
22 affiliated provider was reached and either concurred with
23 the treating non-affiliated provider's plan of care or
24 assumed responsibility for the enrollee's care. Such
25 payment shall be made at the default rate of reimbursement
26 paid under the State's Medicaid fee-for-service program
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1 methodology, including all policy adjusters, including,
2 but not limited to, Medicaid High Volume Adjustments,
3 Medicaid Percentage Adjustments, Outpatient High Volume
4 Adjustments, and all outlier add-on adjustments to the
5 extent that such adjustments are incorporated in the
6 development of the applicable MCO capitated rates.
7 (f) Network adequacy and transparency.
8 (1) The Department shall:
9 (A) ensure that an adequate provider network is in
10 place, taking into consideration health professional
11 shortage areas and medically underserved areas;
12 (B) publicly release an explanation of its process
13 for analyzing network adequacy;
14 (C) periodically ensure that an MCO continues to
15 have an adequate network in place;
16 (D) require MCOs, including Medicaid Managed Care
17 Entities as defined in Section 5-30.2, to meet
18 provider directory requirements under Section 5-30.3;
19 (E) require MCOs to ensure that any
20 Medicaid-certified provider under contract with an MCO
21 and previously submitted on a roster on the date of
22 service is paid for any medically necessary,
23 Medicaid-covered, and authorized service rendered to
24 any of the MCO's enrollees, regardless of inclusion on
25 the MCO's published and publicly available directory
26 of available providers; and
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1 (F) require MCOs, including Medicaid Managed Care
2 Entities as defined in Section 5-30.2, to meet each of
3 the requirements under subsection (d-5) of Section 10
4 of the Network Adequacy and Transparency Act; with
5 necessary exceptions to the MCO's network to ensure
6 that admission and treatment with a provider or at a
7 treatment facility in accordance with the network
8 adequacy standards in paragraph (3) of subsection
9 (d-5) of Section 10 of the Network Adequacy and
10 Transparency Act is limited to providers or facilities
11 that are Medicaid certified.
12 (2) Each MCO shall confirm its receipt of information
13 submitted specific to physician or dentist additions or
14 physician or dentist deletions from the MCO's provider
15 network within 3 days after receiving all required
16 information from contracted physicians or dentists, and
17 electronic physician and dental directories must be
18 updated consistent with current rules as published by the
19 Centers for Medicare and Medicaid Services or its
20 successor agency.
21 (g) Timely payment of claims.
22 (1) The MCO shall pay a claim within 30 days of
23 receiving a claim that contains all the essential
24 information needed to adjudicate the claim.
25 (2) The MCO shall notify the billing party of its
26 inability to adjudicate a claim within 30 days of
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1 receiving that claim.
2 (3) The MCO shall pay a penalty that is at least equal
3 to the timely payment interest penalty imposed under
4 Section 368a of the Illinois Insurance Code for any claims
5 not timely paid.
6 (A) When an MCO is required to pay a timely payment
7 interest penalty to a provider, the MCO must calculate
8 and pay the timely payment interest penalty that is
9 due to the provider within 30 days after the payment of
10 the claim. In no event shall a provider be required to
11 request or apply for payment of any owed timely
12 payment interest penalties.
13 (B) Such payments shall be reported separately
14 from the claim payment for services rendered to the
15 MCO's enrollee and clearly identified as interest
16 payments.
17 (4)(A) The Department shall require MCOs to expedite
18 payments to providers identified on the Department's
19 expedited provider list, determined in accordance with 89
20 Ill. Adm. Code 140.71(b), on a schedule at least as
21 frequently as the providers are paid under the
22 Department's fee-for-service expedited provider schedule.
23 (B) Compliance with the expedited provider requirement
24 may be satisfied by an MCO through the use of a Periodic
25 Interim Payment (PIP) program that has been mutually
26 agreed to and documented between the MCO and the provider,
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1 if the PIP program ensures that any expedited provider
2 receives regular and periodic payments based on prior
3 period payment experience from that MCO. Total payments
4 under the PIP program may be reconciled against future PIP
5 payments on a schedule mutually agreed to between the MCO
6 and the provider.
7 (C) The Department shall share at least monthly its
8 expedited provider list and the frequency with which it
9 pays providers on the expedited list.
10 (g-5) Recognizing that the rapid transformation of the
11 Illinois Medicaid program may have unintended operational
12 challenges for both payers and providers:
13 (1) in no instance shall a medically necessary covered
14 service rendered in good faith, based upon eligibility
15 information documented by the provider, be denied coverage
16 or diminished in payment amount if the eligibility or
17 coverage information available at the time the service was
18 rendered is later found to be inaccurate in the assignment
19 of coverage responsibility between MCOs or the
20 fee-for-service system, except for instances when an
21 individual is deemed to have not been eligible for
22 coverage under the Illinois Medicaid program; and
23 (2) the Department shall, by December 31, 2016, adopt
24 rules establishing policies that shall be included in the
25 Medicaid managed care policy and procedures manual
26 addressing payment resolutions in situations in which a
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1 provider renders services based upon information obtained
2 after verifying a patient's eligibility and coverage plan
3 through either the Department's current enrollment system
4 or a system operated by the coverage plan identified by
5 the patient presenting for services:
6 (A) such medically necessary covered services
7 shall be considered rendered in good faith;
8 (B) such policies and procedures shall be
9 developed in consultation with industry
10 representatives of the Medicaid managed care health
11 plans and representatives of provider associations
12 representing the majority of providers within the
13 identified provider industry; and
14 (C) such rules shall be published for a review and
15 comment period of no less than 30 days on the
16 Department's website with final rules remaining
17 available on the Department's website.
18 The rules on payment resolutions shall include, but
19 not be limited to:
20 (A) the extension of the timely filing period;
21 (B) retroactive prior authorizations; and
22 (C) guaranteed minimum payment rate of no less
23 than the current, as of the date of service,
24 fee-for-service rate, plus all applicable add-ons,
25 when the resulting service relationship is out of
26 network.
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1 The rules shall be applicable for both MCO coverage
2 and fee-for-service coverage.
3 If the fee-for-service system is ultimately determined to
4 have been responsible for coverage on the date of service, the
5 Department shall provide for an extended period for claims
6 submission outside the standard timely filing requirements.
7 (g-6) MCO Performance Metrics Report.
8 (1) The Department shall publish, on at least a
9 quarterly basis, each MCO's operational performance,
10 including, but not limited to, the following categories of
11 metrics:
12 (A) claims payment, including timeliness and
13 accuracy;
14 (B) prior authorizations;
15 (C) grievance and appeals;
16 (D) utilization statistics;
17 (E) provider disputes;
18 (F) provider credentialing; and
19 (G) member and provider customer service.
20 (2) The Department shall ensure that the metrics
21 report is accessible to providers online by January 1,
22 2017.
23 (3) The metrics shall be developed in consultation
24 with industry representatives of the Medicaid managed care
25 health plans and representatives of associations
26 representing the majority of providers within the
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1 identified industry.
2 (4) Metrics shall be defined and incorporated into the
3 applicable Managed Care Policy Manual issued by the
4 Department.
5 (g-7) MCO claims processing and performance analysis. In
6 order to monitor MCO payments to hospital providers, pursuant
7 to Public Act 100-580, the Department shall post an analysis
8 of MCO claims processing and payment performance on its
9 website every 6 months. Such analysis shall include a review
10 and evaluation of a representative sample of hospital claims
11 that are rejected and denied for clean and unclean claims and
12 the top 5 reasons for such actions and timeliness of claims
13 adjudication, which identifies the percentage of claims
14 adjudicated within 30, 60, 90, and over 90 days, and the dollar
15 amounts associated with those claims.
16 (g-8) Dispute resolution process. The Department shall
17 maintain a provider complaint portal through which a provider
18 can submit to the Department unresolved disputes with an MCO.
19 An unresolved dispute means an MCO's decision that denies in
20 whole or in part a claim for reimbursement to a provider for
21 health care services rendered by the provider to an enrollee
22 of the MCO with which the provider disagrees. Disputes shall
23 not be submitted to the portal until the provider has availed
24 itself of the MCO's internal dispute resolution process.
25 Disputes that are submitted to the MCO internal dispute
26 resolution process may be submitted to the Department of
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1 Healthcare and Family Services' complaint portal no sooner
2 than 30 days after submitting to the MCO's internal process
3 and not later than 30 days after the unsatisfactory resolution
4 of the internal MCO process or 60 days after submitting the
5 dispute to the MCO internal process. Multiple claim disputes
6 involving the same MCO may be submitted in one complaint,
7 regardless of whether the claims are for different enrollees,
8 when the specific reason for non-payment of the claims
9 involves a common question of fact or policy. Within 10
10 business days of receipt of a complaint, the Department shall
11 present such disputes to the appropriate MCO, which shall then
12 have 30 days to issue its written proposal to resolve the
13 dispute. The Department may grant one 30-day extension of this
14 time frame to one of the parties to resolve the dispute. If the
15 dispute remains unresolved at the end of this time frame or the
16 provider is not satisfied with the MCO's written proposal to
17 resolve the dispute, the provider may, within 30 days, request
18 the Department to review the dispute and make a final
19 determination. Within 30 days of the request for Department
20 review of the dispute, both the provider and the MCO shall
21 present all relevant information to the Department for
22 resolution and make individuals with knowledge of the issues
23 available to the Department for further inquiry if needed.
24 Within 30 days of receiving the relevant information on the
25 dispute, or the lapse of the period for submitting such
26 information, the Department shall issue a written decision on
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1 the dispute based on contractual terms between the provider
2 and the MCO, contractual terms between the MCO and the
3 Department of Healthcare and Family Services and applicable
4 Medicaid policy. The decision of the Department shall be
5 final. By January 1, 2020, the Department shall establish by
6 rule further details of this dispute resolution process.
7 Disputes between MCOs and providers presented to the
8 Department for resolution are not contested cases, as defined
9 in Section 1-30 of the Illinois Administrative Procedure Act,
10 conferring any right to an administrative hearing.
11 (g-9)(1) The Department shall publish annually on its
12 website a report on the calculation of each managed care
13 organization's medical loss ratio showing the following:
14 (A) Premium revenue, with appropriate adjustments.
15 (B) Benefit expense, setting forth the aggregate
16 amount spent for the following:
17 (i) Direct paid claims.
18 (ii) Subcapitation payments.
19 (iii) Other claim payments.
20 (iv) Direct reserves.
21 (v) Gross recoveries.
22 (vi) Expenses for activities that improve health
23 care quality as allowed by the Department.
24 (2) The medical loss ratio shall be calculated consistent
25 with federal law and regulation following a claims runout
26 period determined by the Department.
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1 (g-10)(1) "Liability effective date" means the date on
2 which an MCO becomes responsible for payment for medically
3 necessary and covered services rendered by a provider to one
4 of its enrollees in accordance with the contract terms between
5 the MCO and the provider. The liability effective date shall
6 be the later of:
7 (A) The execution date of a network participation
8 contract agreement.
9 (B) The date the provider or its representative
10 submits to the MCO the complete and accurate standardized
11 roster form for the provider in the format approved by the
12 Department.
13 (C) The provider effective date contained within the
14 Department's provider enrollment subsystem within the
15 Illinois Medicaid Program Advanced Cloud Technology
16 (IMPACT) System.
17 (2) The standardized roster form may be submitted to the
18 MCO at the same time that the provider submits an enrollment
19 application to the Department through IMPACT.
20 (3) By October 1, 2019, the Department shall require all
21 MCOs to update their provider directory with information for
22 new practitioners of existing contracted providers within 30
23 days of receipt of a complete and accurate standardized roster
24 template in the format approved by the Department provided
25 that the provider is effective in the Department's provider
26 enrollment subsystem within the IMPACT system. Such provider
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1 directory shall be readily accessible for purposes of
2 selecting an approved health care provider and comply with all
3 other federal and State requirements.
4 (g-11) The Department shall work with relevant
5 stakeholders on the development of operational guidelines to
6 enhance and improve operational performance of Illinois'
7 Medicaid managed care program, including, but not limited to,
8 improving provider billing practices, reducing claim
9 rejections and inappropriate payment denials, and
10 standardizing processes, procedures, definitions, and response
11 timelines, with the goal of reducing provider and MCO
12 administrative burdens and conflict. The Department shall
13 include a report on the progress of these program improvements
14 and other topics in its Fiscal Year 2020 annual report to the
15 General Assembly.
16 (g-12) Notwithstanding any other provision of law, if the
17 Department or an MCO requires submission of a claim for
18 payment in a non-electronic format, a provider shall always be
19 afforded a period of no less than 90 business days, as a
20 correction period, following any notification of rejection by
21 either the Department or the MCO to correct errors or
22 omissions in the original submission.
23 Under no circumstances, either by an MCO or under the
24 State's fee-for-service system, shall a provider be denied
25 payment for failure to comply with any timely submission
26 requirements under this Code or under any existing contract,
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1 unless the non-electronic format claim submission occurs after
2 the initial 180 days following the latest date of service on
3 the claim, or after the 90 business days correction period
4 following notification to the provider of rejection or denial
5 of payment.
6 (g-13) Utilization Review Standardization and
7 Transparency.
8 (1) To ensure greater standardization and transparency
9 related to service authorization determinations, for all
10 individuals covered under the medical assistance program,
11 including both the fee-for-service and managed care
12 programs, the Department shall, in consultation with the
13 MCOs, a statewide association representing the MCOs, a
14 statewide association representing the majority of
15 Illinois hospitals, a statewide association representing
16 physicians, or any other interested parties deemed
17 appropriate by the Department, adopt administrative rules
18 consistent with this subsection, in accordance with the
19 Illinois Administrative Procedure Act.
20 (2) No later than Prior to July 1, 2025, the
21 Department shall in accordance with the Illinois
22 Administrative Procedure Act file emergency rules, and
23 adopt permanent rules no later than October 1, 2025, adopt
24 rules which govern MCO practices for dates of services on
25 and after July 1, 2025, as follows:
26 (A) guidelines related to the publication of MCO
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1 authorization policies;
2 (B) procedures that, due to medical complexity,
3 must be reimbursed under the applicable inpatient
4 methodology, when provided in the inpatient setting
5 and billed as an inpatient service;
6 (C) standardization of administrative forms used
7 in the member appeal process;
8 (D) limitations on second or subsequent medical
9 necessity review of a health care service already
10 authorized by the MCO or URO under a service
11 authorization program;
12 (E) standardization of peer-to-peer processes and
13 timelines;
14 (F) defined criteria for urgent and standard
15 post-acute care and long-term acute care service
16 authorization requests; and
17 (G) standardized criteria for service
18 authorization programs for authorization of admission
19 to a long-term acute care hospital.
20 (3) The Department shall expand the scope of the
21 quality and compliance audits conducted by its contracted
22 external quality review organization to include, but not
23 be limited to:
24 (A) an analysis of the Medicaid MCO's compliance
25 with nationally recognized clinical decision
26 guidelines;
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1 (B) an analysis that compares and contrasts the
2 Medicaid MCO's service authorization determination
3 outcomes to the outcomes of each other MCO plan and the
4 State's fee-for-service program model to evaluate
5 whether service authorization determinations are being
6 made consistently by all Medicaid MCOs to ensure that
7 all individuals are being treated in accordance with
8 equitable standards of care;
9 (C) an analysis, for each Medicaid MCO, of the
10 number of service authorization requests, including
11 requests for concurrent review and certification of
12 admissions, received, initially denied, overturned
13 through any post-denial process including, but not
14 limited to, enrollee or provider appeal, peer-to-peer
15 review, or the provider dispute resolution process,
16 denied but approved for a lower or different level of
17 care, and the number denied on final determination;
18 and
19 (D) provide a written report to the General
20 Assembly, detailing the items listed in this
21 subsection and any other metrics deemed necessary by
22 the Department, by the second April, following June 7,
23 2024 (the effective date of Public Act 103-593) this
24 amendatory Act of the 103rd General Assembly, and each
25 April thereafter. The Department shall make this
26 report available within 30 days of delivery to the
SB2437 Enrolled - 183 - LRB104 10548 KTG 20624 b
1 General Assembly, on its public facing website.
2 (h) The Department shall not expand mandatory MCO
3 enrollment into new counties beyond those counties already
4 designated by the Department as of June 1, 2014 for the
5 individuals whose eligibility for medical assistance is not
6 the seniors or people with disabilities population until the
7 Department provides an opportunity for accountable care
8 entities and MCOs to participate in such newly designated
9 counties.
10 (h-5) Leading indicator data sharing. By January 1, 2024,
11 the Department shall obtain input from the Department of Human
12 Services, the Department of Juvenile Justice, the Department
13 of Children and Family Services, the State Board of Education,
14 managed care organizations, providers, and clinical experts to
15 identify and analyze key indicators and data elements that can
16 be used in an analysis of lead indicators from assessments and
17 data sets available to the Department that can be shared with
18 managed care organizations and similar care coordination
19 entities contracted with the Department as leading indicators
20 for elevated behavioral health crisis risk for children,
21 including data sets such as the Illinois Medicaid
22 Comprehensive Assessment of Needs and Strengths (IM-CANS),
23 calls made to the State's Crisis and Referral Entry Services
24 (CARES) hotline, health services information from Health and
25 Human Services Innovators, or other data sets that may include
26 key indicators. The workgroup shall complete its
SB2437 Enrolled - 184 - LRB104 10548 KTG 20624 b
1 recommendations for leading indicator data elements on or
2 before September 1, 2024. To the extent permitted by State and
3 federal law, the identified leading indicators shall be shared
4 with managed care organizations and similar care coordination
5 entities contracted with the Department on or before December
6 1, 2024 for the purpose of improving care coordination with
7 the early detection of elevated risk. Leading indicators shall
8 be reassessed annually with stakeholder input. The Department
9 shall implement guidance to managed care organizations and
10 similar care coordination entities contracted with the
11 Department, so that the managed care organizations and care
12 coordination entities respond to lead indicators with services
13 and interventions that are designed to help stabilize the
14 child.
15 (i) The requirements of this Section apply to contracts
16 with accountable care entities and MCOs entered into, amended,
17 or renewed after June 16, 2014 (the effective date of Public
18 Act 98-651).
19 (j) Health care information released to managed care
20 organizations. A health care provider shall release to a
21 Medicaid managed care organization, upon request, and subject
22 to the Health Insurance Portability and Accountability Act of
23 1996 and any other law applicable to the release of health
24 information, the health care information of the MCO's
25 enrollee, if the enrollee has completed and signed a general
26 release form that grants to the health care provider
SB2437 Enrolled - 185 - LRB104 10548 KTG 20624 b
1 permission to release the recipient's health care information
2 to the recipient's insurance carrier.
3 (k) The Department of Healthcare and Family Services,
4 managed care organizations, a statewide organization
5 representing hospitals, and a statewide organization
6 representing safety-net hospitals shall explore ways to
7 support billing departments in safety-net hospitals.
8 (l) The requirements of this Section added by Public Act
9 102-4 shall apply to services provided on or after the first
10 day of the month that begins 60 days after April 27, 2021 (the
11 effective date of Public Act 102-4).
12 (m) Except where otherwise expressly specified, the
13 requirements of this Section added by Public Act 103-593 this
14 amendatory Act of the 103rd General Assembly shall apply to
15 services provided on and after July 1, 2026 on or after July 1,
16 2025.
17 (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
18 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
19 5-13-22; 103-546, eff. 8-11-23; 103-593, eff. 6-7-24; 103-885,
20 eff. 8-9-24; revised 10-7-24.)
21 (305 ILCS 5/5-30.18)
22 (Section scheduled to be repealed on December 31, 2030)
23 Sec. 5-30.18. Service authorization program performance.
24 (a) Definitions. As used in this Section:
25 "Gold Card provider" means a provider identified by each
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1 Medicaid Managed Care Organization (MCO) as qualified under
2 the guidelines outlined by the Department in accordance with
3 subsection (c) and thereby granted a service authorization
4 exemption when ordering a health care service.
5 "Health care service" means any medical or behavioral
6 health service covered under the medical assistance program
7 that is rendered in the inpatient or outpatient hospital
8 setting, including hospital-based clinics, and subject to
9 review under a service authorization program.
10 "Provider" means an individual actively enrolled in the
11 medical assistance program and licensed or otherwise
12 authorized to order, prescribe, refer, or render health care
13 services in this State, and, as determined by the Department,
14 may also include hospitals that submit service authorization
15 requests.
16 "Service authorization exemption" means an exception
17 granted by a Medicaid MCO to a provider under which all service
18 authorization requests for covered health care services,
19 excluding pharmacy services and durable medical equipment, are
20 automatically deemed to be medically necessary, clinically
21 appropriate, and approved for reimbursement as ordered.
22 "Service authorization program" means any utilization
23 review, utilization management, peer review, quality review,
24 or other medical management activity conducted in advance of,
25 concurrent to, or after the provision of a health care service
26 by a Medicaid MCO, either directly or through a contracted
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1 utilization review organization (URO), including, but not
2 limited to, prior authorization, pre-certification,
3 certification of admission, concurrent review, and
4 retrospective review of health care services.
5 "Service authorization request" means a request by a
6 provider to a service authorization program to determine
7 whether a health care service that is otherwise covered under
8 the medical assistance program meets the reimbursement
9 requirements established by the Medicaid MCO, or its
10 contracted URO, for medically necessary, clinically
11 appropriate care and to issue a service authorization
12 determination.
13 "Utilization review organization" or "URO" means a managed
14 care organization or other entity that has established or
15 administers one or more service authorization programs.
16 (b) In consultation with the Medicaid MCOs, a statewide
17 association representing managed care organizations, a
18 statewide association representing the majority of Illinois
19 hospitals, and a statewide association representing
20 physicians, the Department shall in accordance with the
21 Illinois Administrative Procedure Act, adopt administrative
22 rules no later than July 1, 2026, consistent with this
23 Section, to require each Medicaid MCO to identify Gold Card
24 providers with such identification initially being effective
25 for health care services provided on and after July 1, 2026
26 2025.
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1 (c) The Department shall adopt rules, in accordance with
2 the Illinois Administrative Procedure Act, to implement this
3 Section that include, but are not limited to, the following
4 provisions:
5 (1) Require each Medicaid MCO to provide a service
6 authorization exemption to a provider if the provider has
7 submitted at least 50 service authorization requests to
8 its service authorization program in the preceding
9 calendar year and the service authorization program
10 approved at least 90% of all service authorization
11 requests, regardless of the type of health care services
12 requested.
13 (2) Require that service authorization exemptions be
14 limited to services provided in an inpatient or outpatient
15 hospital setting inclusive of hospital-based clinics.
16 Service authorization exemptions under this Section shall
17 not pertain to pharmacy services and durable medical
18 equipment and supplies.
19 (3) The service authorization exemption shall be valid
20 for at least one year, shall be made by each Medicaid MCO
21 or its URO, and shall be binding on the Medicaid MCO and
22 its URO.
23 (4) The provider shall be required to continue to
24 document medically necessary, clinically appropriate care
25 and submit such documentation to the Medicaid MCO for the
26 purpose of continuous performance monitoring. If a
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1 provider fails to maintain the 90% service authorization
2 standard, as determined on no more frequent a basis than
3 bi-annually, the provider's service authorization
4 exemption is subject to temporary or permanent suspension.
5 (5) Require that each Medicaid MCO publish on its
6 provider portal a list of all providers that have
7 qualified for a service authorization exemption or
8 indicate that a provider has qualified for a service
9 authorization exemption on its provider-facing provider
10 roster.
11 (6) Require that no later than June 1 December 1 of
12 each calendar year, each Medicaid MCO shall provide
13 written notification to all providers who qualify for a
14 service authorization exemption, for the subsequent State
15 fiscal calendar year.
16 (7) Require that each Medicaid MCO or its URO use the
17 policies and guidelines published by the Department to
18 evaluate whether a provider meets the criteria to qualify
19 for a service authorization exemption and the conditions
20 under which a service authorization exemption may be
21 rescinded, including review of the provider's service
22 authorization determinations during the preceding calendar
23 year.
24 (8) Require each Medicaid MCO to provide the
25 Department a list of all providers who were denied a
26 service authorization exemption or had a previously
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1 granted service authorization exemption suspended, with
2 such denials being subject to an annual audit conducted by
3 an independent third-party URO to ensure their
4 appropriateness.
5 (A) The independent third-party URO shall issue a
6 written report consistent with this paragraph.
7 (B) The independent third-party URO shall not be
8 owned by, affiliated with, or employed by any Medicaid
9 MCO or its contracted URO, nor shall it have any
10 financial interest in the Medicaid MCO's service
11 authorization exemption program.
12 (d) Each Medicaid MCO must have a standard method to
13 accept and process professional claims and facility claims, as
14 billed by the provider, for a health care service that is
15 rendered, prescribed, or ordered by a provider granted a
16 service authorization exemption, except in cases of fraud.
17 (e) A service authorization program shall not deny,
18 partially deny, reduce the level of care, or otherwise limit
19 reimbursement to the rendering or supervising provider,
20 including the rendering facility, for health care services
21 ordered by a provider who qualifies for a service
22 authorization exemption, except in cases of fraud.
23 (f) This Section is repealed on December 31, 2030.
24 (Source: P.A. 103-593, eff. 6-7-24.)
25 ARTICLE 72.
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1 Section 72-5. The Hospital Licensing Act is amended by
2 changing Section 4.5 as follows:
3 (210 ILCS 85/4.5)
4 Sec. 4.5. Hospital with multiple locations; single
5 license.
6 (a) A hospital located in a county with fewer than
7 3,000,000 inhabitants may apply to the Department for approval
8 to conduct its operations from more than one location within
9 the county under a single license. At the time of the
10 application to operate under a single license, a hospital
11 located in a county with fewer than 125,000 inhabitants may
12 apply to the Department for approval to conduct its operations
13 from more than one location within contiguous counties in
14 which both facilities are located, provided that the second
15 county has fewer than 235,000 inhabitants. A hospital located
16 in a county with fewer than 325,000 inhabitants may apply to
17 the Department for approval to conduct its operations from
18 more than one location within contiguous counties provided
19 that the facility located in the contiguous county is
20 separately licensed under this Act and was acquired out of
21 bankruptcy proceedings under the United States Bankruptcy Code
22 before the effective date of this amendatory Act of the 104th
23 General Assembly.
24 (b) The facilities or buildings at those locations must be
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1 owned or operated together by a single corporation or other
2 legal entity serving as the licensee and must share:
3 (1) a single board of directors with responsibility
4 for governance, including financial oversight and the
5 authority to designate or remove the chief executive
6 officer;
7 (2) a single medical staff accountable to the board of
8 directors and governed by a single set of medical staff
9 bylaws, rules, and regulations with responsibility for the
10 quality of the medical services; and
11 (3) a single chief executive officer, accountable to
12 the board of directors, with management responsibility.
13 (c) Each hospital building or facility that is located on
14 a site geographically separate from the campus or premises of
15 another hospital building or facility operated by the licensee
16 must, at a minimum, individually comply with the Department's
17 hospital licensing requirements for emergency services.
18 (d) The hospital shall submit to the Department a
19 comprehensive plan in relation to the waiver or waivers
20 requested describing the services and operations of each
21 facility or building and how common services or operations
22 will be coordinated between the various locations. With the
23 exception of items required by subsection (c), the Department
24 is authorized to waive compliance with the hospital licensing
25 requirements for specific buildings or facilities, provided
26 that the hospital has documented which other building or
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1 facility under its single license provides that service or
2 operation, and that doing so would not endanger the public's
3 health, safety, or welfare. Nothing in this Section relieves a
4 hospital from the requirements of the Health Facilities
5 Planning Act.
6 (Source: P.A. 102-887, eff. 5-17-22; 103-1075, eff. 3-21-25.)
7 ARTICLE 73.
8 Section 73-5. The Nursing Home Care Act is amended by
9 changing Sections 3-202.05 and 3-209 as follows:
10 (210 ILCS 45/3-202.05)
11 Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
12 thereafter.
13 (a) For the purpose of computing staff to resident ratios,
14 direct care staff shall include:
15 (1) registered nurses;
16 (2) licensed practical nurses;
17 (3) certified nurse assistants;
18 (4) psychiatric services rehabilitation aides;
19 (5) rehabilitation and therapy aides;
20 (6) psychiatric services rehabilitation coordinators;
21 (7) assistant directors of nursing;
22 (8) 50% of the Director of Nurses' time; and
23 (9) 30% of the Social Services Directors' time.
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1 The Department shall, by rule, allow certain facilities
2 subject to 77 Ill. Adm. Code 300.4000 and following (Subpart
3 S) to utilize specialized clinical staff, as defined in rules,
4 to count towards the staffing ratios.
5 Within 120 days of June 14, 2012 (the effective date of
6 Public Act 97-689), the Department shall promulgate rules
7 specific to the staffing requirements for facilities federally
8 defined as Institutions for Mental Disease. These rules shall
9 recognize the unique nature of individuals with chronic mental
10 health conditions, shall include minimum requirements for
11 specialized clinical staff, including clinical social workers,
12 psychiatrists, psychologists, and direct care staff set forth
13 in paragraphs (4) through (6) and any other specialized staff
14 which may be utilized and deemed necessary to count toward
15 staffing ratios.
16 Within 120 days of June 14, 2012 (the effective date of
17 Public Act 97-689), the Department shall promulgate rules
18 specific to the staffing requirements for facilities licensed
19 under the Specialized Mental Health Rehabilitation Act of
20 2013. These rules shall recognize the unique nature of
21 individuals with chronic mental health conditions, shall
22 include minimum requirements for specialized clinical staff,
23 including clinical social workers, psychiatrists,
24 psychologists, and direct care staff set forth in paragraphs
25 (4) through (6) and any other specialized staff which may be
26 utilized and deemed necessary to count toward staffing ratios.
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1 (a-5) The Centers for Medicare and Medicaid Services'
2 payroll-based journal job title codes, which correspond to the
3 staff used for the staffing ratios in subsection (a), are as
4 follows:
5 (1) Registered Nurse Director of Nursing, job title
6 code 5.
7 (2) Registered Nurse with Administrative Duties, job
8 title code 6.
9 (3) Registered Nurse, job title code 7.
10 (4) Licensed Practical/Vocational Nurse with
11 Administrative Duties, job title code 8.
12 (5) Licensed Practical/Vocational Nurse, job title
13 code 9.
14 (6) Certified Nurse Aide, job title code 10.
15 (7) Nurse Aide in Training, job title code 11.
16 (8) Medication Aide/Technician, job title code 12.
17 (9) Nurse Practitioner, job title code 13.
18 (10) Clinical Nurse Specialist, job title code 14.
19 (11) Occupational Therapist, job title code 18.
20 (12) Occupational Therapy Assistant, job title code
21 19.
22 (13) Occupational Therapy Aide, job title code 20.
23 (14) Physical Therapist, job title code 21.
24 (15) Physical Therapy Assistant, job title code 22.
25 (16) Physical Therapy Assistant, job title code 23.
26 (17) Respiratory Therapist, job title code 24.
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1 (18) Respiratory Therapy Technician, job title code
2 25.
3 (19) Speech/Language Pathologist, job title code 26.
4 (20) Qualified Activities Professional, job title code
5 28.
6 (21) Other Activities Staff, job title code 29.
7 (22) Qualified Social Worker, job title code 30.
8 (23) Other Social Worker, job title code 31.
9 (24) Mental Health Service Worker, job title code 34.
10 For all job title codes in this subsection, 100% of the
11 hours worked by the staff must be counted toward the
12 staff-to-resident ratio, except job code title 5, which is
13 limited to 50%, and job title codes 28, 30, and 31, which are
14 limited to 30%.
15 (b) (Blank).
16 (b-5) For purposes of the minimum staffing ratios in this
17 Section, all residents shall be classified as requiring either
18 skilled care or intermediate care.
19 As used in this subsection:
20 "Intermediate care" means basic nursing care and other
21 restorative services under periodic medical direction.
22 "Skilled care" means skilled nursing care, continuous
23 skilled nursing observations, restorative nursing, and other
24 services under professional direction with frequent medical
25 supervision.
26 (c) Facilities shall notify the Department within 60 days
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1 after July 29, 2010 (the effective date of Public Act
2 96-1372), in a form and manner prescribed by the Department,
3 of the staffing ratios in effect on July 29, 2010 (the
4 effective date of Public Act 96-1372) for both intermediate
5 and skilled care and the number of residents receiving each
6 level of care.
7 (d)(1) (Blank).
8 (2) (Blank).
9 (3) (Blank).
10 (4) (Blank).
11 (5) Effective January 1, 2014, the minimum staffing ratios
12 shall be increased to 3.8 hours of nursing and personal care
13 each day for a resident needing skilled care and 2.5 hours of
14 nursing and personal care each day for a resident needing
15 intermediate care.
16 (e) Ninety days after June 14, 2012 (the effective date of
17 Public Act 97-689), a minimum of 25% of nursing and personal
18 care time shall be provided by licensed nurses, with at least
19 10% of nursing and personal care time provided by registered
20 nurses. These minimum requirements shall remain in effect
21 until an acuity based registered nurse requirement is
22 promulgated by rule concurrent with the adoption of the
23 Resource Utilization Group classification-based payment
24 methodology, as provided in Section 5-5.2 of the Illinois
25 Public Aid Code. Registered nurses and licensed practical
26 nurses employed by a facility in excess of these requirements
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1 may be used to satisfy the remaining 75% of the nursing and
2 personal care time requirements. Notwithstanding this
3 subsection, no staffing requirement in statute in effect on
4 June 14, 2012 (the effective date of Public Act 97-689) shall
5 be reduced on account of this subsection.
6 (f) The Department shall submit proposed rules for
7 adoption by January 1, 2020 establishing a system for
8 determining compliance with minimum staffing set forth in this
9 Section and the requirements of 77 Ill. Adm. Code 300.1230
10 adjusted for any waivers granted under Section 3-303.1.
11 Compliance shall be determined quarterly by comparing the
12 number of hours provided per resident per day using the
13 Centers for Medicare and Medicaid Services' payroll-based
14 journal and the facility's daily census, broken down by
15 intermediate and skilled care as self-reported by the facility
16 to the Department on a quarterly basis. The Department shall
17 use the quarterly payroll-based journal and the self-reported
18 census to calculate the number of hours provided per resident
19 per day and compare this ratio to the minimum staffing
20 standards required under this Section, as impacted by any
21 waivers granted under Section 3-303.1. Discrepancies between
22 job titles contained in this Section and the payroll-based
23 journal shall be addressed by rule. The manner in which the
24 Department requests payroll-based journal information to be
25 submitted shall align with the federal Centers for Medicare
26 and Medicaid Services' requirements that allow providers to
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1 submit the quarterly data in an aggregate manner.
2 (g) Monetary penalties for non-compliance. The Department
3 shall submit proposed rules for adoption by January 1, 2020
4 establishing monetary penalties for facilities not in
5 compliance with minimum staffing standards under this Section.
6 Facilities shall be required to comply with the provisions of
7 this subsection beginning January 1, 2025. No monetary penalty
8 may be issued for noncompliance prior to the revised
9 implementation date, which shall be January 1, 2025. If a
10 facility is found to be noncompliant prior to the revised
11 implementation date, the Department shall provide a written
12 notice identifying the staffing deficiencies and require the
13 facility to provide a sufficiently detailed correction plan
14 that describes proposed and completed actions the facility
15 will take or has taken, including hiring actions, to address
16 the facility's failure to meet the statutory minimum staffing
17 levels. Monetary penalties shall be imposed beginning no later
18 than July 1, 2025, based on data for the quarter beginning
19 January 1, 2025 through March 31, 2025 and quarterly
20 thereafter. Monetary penalties shall be established based on a
21 formula that calculates on a daily basis the cost of wages and
22 benefits for the missing staffing hours. All notices of
23 noncompliance shall include the computations used to determine
24 noncompliance and establishing the variance between minimum
25 staffing ratios and the Department's computations. The penalty
26 for the first offense shall be 125% of the cost of wages and
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1 benefits for the missing staffing hours. The penalty shall
2 increase to 150% of the cost of wages and benefits for the
3 missing staffing hours for the second offense and 200% the
4 cost of wages and benefits for the missing staffing hours for
5 the third and all subsequent offenses. The penalty shall be
6 imposed regardless of whether the facility has committed other
7 violations of this Act during the same period that the
8 staffing offense occurred. The penalty may not be waived,
9 except but the Department shall have the discretion to
10 determine the gravity of the violation in situations where
11 there is no more than a 10% deviation from the staffing
12 requirements, in which case the facility shall not receive a
13 violation or penalty and make appropriate adjustments to the
14 penalty. The Department is granted discretion to waive the
15 violation and penalty when unforeseen circumstances have
16 occurred that resulted in call-offs of scheduled staff. This
17 provision shall be applied no more than 6 times per quarter.
18 Nothing in this Section diminishes a facility's right to
19 appeal the imposition of a monetary penalty. No facility may
20 appeal a notice of noncompliance issued during the revised
21 implementation period. The changes made to this subsection by
22 this amendatory Act of the 104th General Assembly in regard to
23 nursing home staffing fines shall apply to the July 1, 2025
24 fines based on data for the quarter beginning January 1, 2025
25 through March 31, 2025 and quarterly thereafter.
26 (Source: P.A. 101-10, eff. 6-5-19; 102-16, eff. 6-17-21;
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1 102-1118, eff. 1-18-23.)
2 (210 ILCS 45/3-209) (from Ch. 111 1/2, par. 4153-209)
3 (Text of Section before amendment by P.A. 103-1069)
4 Sec. 3-209. Required posting of information.
5 (a) Every facility shall conspicuously post for display in
6 an area of its offices accessible to residents, employees, and
7 visitors the following:
8 (1) Its current license;
9 (2) A description, provided by the Department, of
10 complaint procedures established under this Act and the
11 name, address, and telephone number of a person authorized
12 by the Department to receive complaints;
13 (3) A copy of any order pertaining to the facility
14 issued by the Department or a court;
15 (4) A list of the material available for public
16 inspection under Section 3-210;
17 (5) Phone numbers and websites for rights protection
18 services must be posted in common areas and at the main
19 entrance and provided upon entry and at the request of
20 residents or the resident's representative in accordance
21 with 42 CFR 483.10(j)(4); and
22 (6) The statement "The Illinois Long-Term Care
23 Ombudsman Program is a free resident advocacy service
24 available to the public.".
25 In accordance with F574 of the State Operations Manual for
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1 Long-Term Care Facilities, the administrator shall post for
2 all residents and at the main entrance the name, address, and
3 telephone number of the appropriate State governmental office
4 where complaints may be lodged in language the resident can
5 understand, which must include notice of the grievance
6 procedure of the facility or program as well as addresses and
7 phone numbers for the Office of Health Care Regulation and the
8 Long-Term Care Ombudsman Program and a website showing the
9 information of a facility's ownership. The facility shall
10 include a link to the Long-Term Care Ombudsman Program's
11 website on the home page of the facility's website.
12 (b) A facility that has received a notice of violation for
13 a violation of the minimum staffing requirements under Section
14 3-202.05 shall display, for a consecutive 60 days immediately
15 after the facility is notified of the violation during the
16 period of time the facility is out of compliance, a notice
17 stating in Calibri (body) font and 26-point type in black
18 letters on an 8.5 by 11 inch white paper the following:
19 "Notice Dated: ...................
20 This facility did does not currently meet the minimum staffing
21 ratios required by law for [insert applicable quarter]. Posted
22 at the direction of the Illinois Department of Public
23 Health.".
24 The notice must be posted, at a minimum, at all publicly used
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1 exterior entryways into the facility, inside the main entrance
2 lobby, and next to any registration desk for easily accessible
3 viewing. The notice must also be posted on the main page of the
4 facility's website. The Department shall have the discretion
5 to determine the gravity of any violation and, taking into
6 account mitigating and aggravating circumstances and facts,
7 may reduce the requirement of, and amount of time for, posting
8 the notice. Facilities shall not be required to post for the
9 violation if they are within the 10% deviation of staffing
10 requirements as provided in Section 3-202.05.
11 (Source: P.A. 101-10, eff. 6-5-19; 102-1080, eff. 1-1-23.)
12 (Text of Section after amendment by P.A. 103-1069)
13 Sec. 3-209. Required posting of information.
14 (a) Every facility shall conspicuously post for display in
15 an area of its offices accessible to residents, employees, and
16 visitors the following:
17 (1) Its current license;
18 (2) A description, provided by the Department, of
19 complaint procedures established under this Act and the
20 name, address, and telephone number of a person authorized
21 by the Department to receive complaints;
22 (3) A copy of any order pertaining to the facility
23 issued by the Department or a court;
24 (4) A list of the material available for public
25 inspection under Section 3-210;
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1 (5) Phone numbers and websites for rights protection
2 services must be posted in common areas and at the main
3 entrance and provided upon entry and at the request of
4 residents or the resident's representative in accordance
5 with 42 CFR 483.10(j)(4);
6 (6) The statement "The Illinois Long-Term Care
7 Ombudsman Program is a free resident advocacy service
8 available to the public."; and
9 (7) A description of the retaliation complaint
10 procedures and the remedies established under this Act.
11 In accordance with F574 of the State Operations Manual for
12 Long-Term Care Facilities, the administrator shall post for
13 all residents and at the main entrance the name, address, and
14 telephone number of the appropriate State governmental office
15 where complaints may be lodged in language the resident can
16 understand, which must include notice of the grievance
17 procedure of the facility or program as well as addresses and
18 phone numbers for the Office of Health Care Regulation and the
19 Long-Term Care Ombudsman Program and a website showing the
20 information of a facility's ownership. The facility shall
21 include a link to the Long-Term Care Ombudsman Program's
22 website on the home page of the facility's website.
23 (b) A facility that has received a notice of violation for
24 a violation of the minimum staffing requirements under Section
25 3-202.05 shall display, for a consecutive 60 days immediately
26 after the facility is notified of the violation during the
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1 period of time the facility is out of compliance, a notice
2 stating in Calibri (body) font and 26-point type in black
3 letters on an 8.5 by 11 inch white paper the following:
4 "Notice Dated: ...................
5 This facility did does not currently meet the minimum staffing
6 ratios required by law for [insert applicable quarter]. Posted
7 at the direction of the Illinois Department of Public
8 Health.".
9 The notice must be posted, at a minimum, at all publicly used
10 exterior entryways into the facility, inside the main entrance
11 lobby, and next to any registration desk for easily accessible
12 viewing. The notice must also be posted on the main page of the
13 facility's website. The Department shall have the discretion
14 to determine the gravity of any violation and, taking into
15 account mitigating and aggravating circumstances and facts,
16 may reduce the requirement of, and amount of time for, posting
17 the notice. Facilities shall not be required to post for the
18 violation if they are within the 10% deviation of staffing
19 requirements as provided in Section 3-202.05.
20 (Source: P.A. 102-1080, eff. 1-1-23; 103-1069, eff. 1-1-26.)
21 ARTICLE 74.
22 Section 74-5. The Illinois Public Aid Code is amended by
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1 changing Section 5-5.01a as follows:
2 (305 ILCS 5/5-5.01a)
3 Sec. 5-5.01a. Supportive living facilities program.
4 (a) The Department shall establish and provide oversight
5 for a program of supportive living facilities that seek to
6 promote resident independence, dignity, respect, and
7 well-being in the most cost-effective manner.
8 A supportive living facility is (i) a free-standing
9 facility or (ii) a distinct physical and operational entity
10 within a mixed-use building that meets the criteria
11 established in subsection (d). A supportive living facility
12 integrates housing with health, personal care, and supportive
13 services and is a designated setting that offers residents
14 their own separate, private, and distinct living units.
15 Sites for the operation of the program shall be selected
16 by the Department based upon criteria that may include the
17 need for services in a geographic area, the availability of
18 funding, and the site's ability to meet the standards.
19 (b) Beginning July 1, 2014, subject to federal approval,
20 the Medicaid rates for supportive living facilities shall be
21 equal to the supportive living facility Medicaid rate
22 effective on June 30, 2014 increased by 8.85%. Once the
23 assessment imposed at Article V-G of this Code is determined
24 to be a permissible tax under Title XIX of the Social Security
25 Act, the Department shall increase the Medicaid rates for
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1 supportive living facilities effective on July 1, 2014 by
2 9.09%. The Department shall apply this increase retroactively
3 to coincide with the imposition of the assessment in Article
4 V-G of this Code in accordance with the approval for federal
5 financial participation by the Centers for Medicare and
6 Medicaid Services.
7 The Medicaid rates for supportive living facilities
8 effective on July 1, 2017 must be equal to the rates in effect
9 for supportive living facilities on June 30, 2017 increased by
10 2.8%.
11 The Medicaid rates for supportive living facilities
12 effective on July 1, 2018 must be equal to the rates in effect
13 for supportive living facilities on June 30, 2018.
14 Subject to federal approval, the Medicaid rates for
15 supportive living services on and after July 1, 2019 must be at
16 least 54.3% of the average total nursing facility services per
17 diem for the geographic areas defined by the Department while
18 maintaining the rate differential for dementia care and must
19 be updated whenever the total nursing facility service per
20 diems are updated. Beginning July 1, 2022, upon the
21 implementation of the Patient Driven Payment Model, Medicaid
22 rates for supportive living services must be at least 54.3% of
23 the average total nursing services per diem rate for the
24 geographic areas. For purposes of this provision, the average
25 total nursing services per diem rate shall include all add-ons
26 for nursing facilities for the geographic area provided for in
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1 Section 5-5.2. The rate differential for dementia care must be
2 maintained in these rates and the rates shall be updated
3 whenever nursing facility per diem rates are updated.
4 Subject to federal approval, beginning January 1, 2024,
5 the dementia care rate for supportive living services must be
6 no less than the non-dementia care supportive living services
7 rate multiplied by 1.5.
8 (b-5) Subject to federal approval, beginning January 1,
9 2025, Medicaid rates for supportive living services must be at
10 least 54.75% of the average total nursing facility services
11 per diem rate for the geographic areas defined by the
12 Department and shall include all add-ons for nursing
13 facilities for the geographic area provided for in Section
14 5-5.2.
15 (c) The Department may adopt rules to implement this
16 Section. Rules that establish or modify the services,
17 standards, and conditions for participation in the program
18 shall be adopted by the Department in consultation with the
19 Department on Aging, the Department of Rehabilitation
20 Services, and the Department of Mental Health and
21 Developmental Disabilities (or their successor agencies).
22 (d) Subject to federal approval by the Centers for
23 Medicare and Medicaid Services, the Department shall accept
24 for consideration of certification under the program any
25 application for a site or building where distinct parts of the
26 site or building are designated for purposes other than the
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1 provision of supportive living services, but only if:
2 (1) those distinct parts of the site or building are
3 not designated for the purpose of providing assisted
4 living services as required under the Assisted Living and
5 Shared Housing Act;
6 (2) those distinct parts of the site or building are
7 completely separate from the part of the building used for
8 the provision of supportive living program services,
9 including separate entrances;
10 (3) those distinct parts of the site or building do
11 not share any common spaces with the part of the building
12 used for the provision of supportive living program
13 services; and
14 (4) those distinct parts of the site or building do
15 not share staffing with the part of the building used for
16 the provision of supportive living program services.
17 (e) Facilities or distinct parts of facilities which are
18 selected as supportive living facilities and are in good
19 standing with the Department's rules are exempt from the
20 provisions of the Nursing Home Care Act and the Illinois
21 Health Facilities Planning Act.
22 (f) Section 9817 of the American Rescue Plan Act of 2021
23 (Public Law 117-2) authorizes a 10% enhanced federal medical
24 assistance percentage for supportive living services for a
25 12-month period from April 1, 2021 through March 31, 2022.
26 Subject to federal approval, including the approval of any
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1 necessary waiver amendments or other federally required
2 documents or assurances, for a 12-month period the Department
3 must pay a supplemental $26 per diem rate to all supportive
4 living facilities with the additional federal financial
5 participation funds that result from the enhanced federal
6 medical assistance percentage from April 1, 2021 through March
7 31, 2022. The Department may issue parameters around how the
8 supplemental payment should be spent, including quality
9 improvement activities. The Department may alter the form,
10 methods, or timeframes concerning the supplemental per diem
11 rate to comply with any subsequent changes to federal law,
12 changes made by guidance issued by the federal Centers for
13 Medicare and Medicaid Services, or other changes necessary to
14 receive the enhanced federal medical assistance percentage.
15 (g) All applications for the expansion of supportive
16 living dementia care settings involving sites not approved by
17 the Department by January 1, 2024 (Public Act 103-102) may
18 allow new elderly non-dementia units in addition to new
19 dementia care units. The Department may approve such
20 applications only if the application has: (1) no more than one
21 non-dementia care unit for each dementia care unit and (2) the
22 site is not located within 4 miles of an existing supportive
23 living program site in Cook County (including the City of
24 Chicago), not located within 12 miles of an existing
25 supportive living program site in Alexander, Bond, Boone,
26 Calhoun, Champaign, Clinton, DeKalb, DuPage Fulton, Grundy,
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1 Henry, Jackson, Jersey, Johnson, Kane, Kankakee, Kendall,
2 Lake, Macon, Macoupin, Madison, Marshall, McHenry, McLean,
3 Menard, Mercer, Monroe, Peoria, Piatt, Rock Island, Sangamon,
4 Stark, St. Clair, Tazewell, Vermilion, Will, Williamson,
5 Winnebago, or Woodford counties, or not located within 25
6 miles of an existing supportive living program site in any
7 other county.
8 (h) Beginning January 1, 2025, subject to federal
9 approval, for a person who is a resident of a supportive living
10 facility under this Section, the monthly personal needs
11 allowance shall be $120 per month.
12 (i) (h) As stated in the supportive living program home
13 and community-based service waiver approved by the federal
14 Centers for Medicare and Medicaid Services, and beginning July
15 1, 2025, the Department must maintain the rate add-on
16 implemented on January 1, 2023 for the provision of 2 meals per
17 day at no less than $6.15 per day.
18 (j) (f) Subject to federal approval, the Department shall
19 allow a certified medication aide to administer medication in
20 a supportive living facility. For purposes of this subsection,
21 "certified medication aide" means a person who has met the
22 qualifications for certification under Section 79 of the
23 Assisted Living and Shared Housing Act and assists with
24 medication administration while under the supervision of a
25 registered professional nurse as authorized by Section 50-75
26 of the Nurse Practice Act. The Department may adopt rules to
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1 implement this subsection.
2 (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
3 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
4 Article 100, Section 100-5, eff. 1-1-24; 103-593, Article 15,
5 Section 15-5, eff. 6-7-24; 103-593, Article 100, Section
6 100-5, eff. 6-7-24; 103-593, Article 165, Section 165-5, eff.
7 6-7-24; 103-605, eff. 7-1-24; 103-886, eff. 8-9-24; revised
8 10-8-24.)
9 ARTICLE 75.
10 Section 75-5. The Illinois Public Aid Code is amended by
11 changing Section 5A-2 as follows:
12 (305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)
13 (Section scheduled to be repealed on December 31, 2026)
14 Sec. 5A-2. Assessment.
15 (a)(1) Subject to Sections 5A-3 and 5A-10, for State
16 fiscal years 2009 through 2018, or as long as continued under
17 Section 5A-16, an annual assessment on inpatient services is
18 imposed on each hospital provider in an amount equal to
19 $218.38 multiplied by the difference of the hospital's
20 occupied bed days less the hospital's Medicare bed days,
21 provided, however, that the amount of $218.38 shall be
22 increased by a uniform percentage to generate an amount equal
23 to 75% of the State share of the payments authorized under
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1 Section 5A-12.5, with such increase only taking effect upon
2 the date that a State share for such payments is required under
3 federal law. For the period of April through June 2015, the
4 amount of $218.38 used to calculate the assessment under this
5 paragraph shall, by emergency rule under subsection (s) of
6 Section 5-45 of the Illinois Administrative Procedure Act, be
7 increased by a uniform percentage to generate $20,250,000 in
8 the aggregate for that period from all hospitals subject to
9 the annual assessment under this paragraph.
10 (2) In addition to any other assessments imposed under
11 this Article, effective July 1, 2016 and semi-annually
12 thereafter through June 2018, or as provided in Section 5A-16,
13 in addition to any federally required State share as
14 authorized under paragraph (1), the amount of $218.38 shall be
15 increased by a uniform percentage to generate an amount equal
16 to 75% of the ACA Assessment Adjustment, as defined in
17 subsection (b-6) of this Section.
18 For State fiscal years 2009 through 2018, or as provided
19 in Section 5A-16, a hospital's occupied bed days and Medicare
20 bed days shall be determined using the most recent data
21 available from each hospital's 2005 Medicare cost report as
22 contained in the Healthcare Cost Report Information System
23 file, for the quarter ending on December 31, 2006, without
24 regard to any subsequent adjustments or changes to such data.
25 If a hospital's 2005 Medicare cost report is not contained in
26 the Healthcare Cost Report Information System, then the
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1 Illinois Department may obtain the hospital provider's
2 occupied bed days and Medicare bed days from any source
3 available, including, but not limited to, records maintained
4 by the hospital provider, which may be inspected at all times
5 during business hours of the day by the Illinois Department or
6 its duly authorized agents and employees.
7 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
8 fiscal years 2019 and 2020, an annual assessment on inpatient
9 services is imposed on each hospital provider in an amount
10 equal to $197.19 multiplied by the difference of the
11 hospital's occupied bed days less the hospital's Medicare bed
12 days. For State fiscal years 2019 and 2020, a hospital's
13 occupied bed days and Medicare bed days shall be determined
14 using the most recent data available from each hospital's 2015
15 Medicare cost report as contained in the Healthcare Cost
16 Report Information System file, for the quarter ending on
17 March 31, 2017, without regard to any subsequent adjustments
18 or changes to such data. If a hospital's 2015 Medicare cost
19 report is not contained in the Healthcare Cost Report
20 Information System, then the Illinois Department may obtain
21 the hospital provider's occupied bed days and Medicare bed
22 days from any source available, including, but not limited to,
23 records maintained by the hospital provider, which may be
24 inspected at all times during business hours of the day by the
25 Illinois Department or its duly authorized agents and
26 employees. Notwithstanding any other provision in this
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1 Article, for a hospital provider that did not have a 2015
2 Medicare cost report, but paid an assessment in State fiscal
3 year 2018 on the basis of hypothetical data, that assessment
4 amount shall be used for State fiscal years 2019 and 2020.
5 (4) Subject to Sections 5A-3 and 5A-10 and to subsection
6 (b-8), for the period of July 1, 2020 through December 31, 2020
7 and calendar years 2021 through 2026, an annual assessment on
8 inpatient services is imposed on each hospital provider in an
9 amount equal to $221.50 multiplied by the difference of the
10 hospital's occupied bed days less the hospital's Medicare bed
11 days, provided however: for the period of July 1, 2020 through
12 December 31, 2020, (i) the assessment shall be equal to 50% of
13 the annual amount; and (ii) the amount of $221.50 shall be
14 retroactively adjusted by a uniform percentage to generate an
15 amount equal to 50% of the Assessment Adjustment, as defined
16 in subsection (b-7). For the period of July 1, 2020 through
17 December 31, 2020 and calendar years 2021 through 2026, a
18 hospital's occupied bed days and Medicare bed days shall be
19 determined using the most recent data available from each
20 hospital's 2015 Medicare cost report as contained in the
21 Healthcare Cost Report Information System file, for the
22 quarter ending on March 31, 2017, without regard to any
23 subsequent adjustments or changes to such data. If a
24 hospital's 2015 Medicare cost report is not contained in the
25 Healthcare Cost Report Information System, then the Illinois
26 Department may obtain the hospital provider's occupied bed
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1 days and Medicare bed days from any source available,
2 including, but not limited to, records maintained by the
3 hospital provider, which may be inspected at all times during
4 business hours of the day by the Illinois Department or its
5 duly authorized agents and employees. Should the change in the
6 assessment methodology for fiscal years 2021 through December
7 31, 2022 not be approved on or before June 30, 2020, the
8 assessment and payments under this Article in effect for
9 fiscal year 2020 shall remain in place until the new
10 assessment is approved. If the assessment methodology for July
11 1, 2020 through December 31, 2022, is approved on or after July
12 1, 2020, it shall be retroactive to July 1, 2020, subject to
13 federal approval and provided that the payments authorized
14 under Section 5A-12.7 have the same effective date as the new
15 assessment methodology. In giving retroactive effect to the
16 assessment approved after June 30, 2020, credit toward the new
17 assessment shall be given for any payments of the previous
18 assessment for periods after June 30, 2020. Notwithstanding
19 any other provision of this Article, for a hospital provider
20 that did not have a 2015 Medicare cost report, but paid an
21 assessment in State Fiscal Year 2020 on the basis of
22 hypothetical data, the data that was the basis for the 2020
23 assessment shall be used to calculate the assessment under
24 this paragraph until December 31, 2023. Beginning July 1, 2022
25 and through December 31, 2024, a safety-net hospital that had
26 a change of ownership in calendar year 2021, and whose
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1 inpatient utilization had decreased by 90% from the prior year
2 and prior to the change of ownership, may be eligible to pay a
3 tax based on hypothetical data based on a determination of
4 financial distress by the Department. Subject to federal
5 approval, the Department may, by January 1, 2024, develop a
6 hypothetical tax for a specialty cancer hospital which had a
7 structural change of ownership during calendar year 2022 from
8 a for-profit entity to a non-profit entity, and which has
9 experienced a decline of 60% or greater in inpatient days of
10 care as compared to the prior owners 2015 Medicare cost
11 report. This change of ownership may make the hospital
12 eligible for a hypothetical tax under the new hospital
13 provision of the assessment defined in this Section. This new
14 hypothetical tax may be applicable from January 1, 2024
15 through December 31, 2026.
16 (6) For calendar year 2026, and for each year thereafter
17 in which a tax is imposed under this Section, the Department
18 may seek to obtain a waiver from the federal Centers for
19 Medicare and Medicaid Services of the uniformity requirements
20 in place for the tax imposed under this Section, provided that
21 such waiver request does not risk the assessment imposed or
22 payments authorized under this Section from continuing. Such
23 uniformity requirements shall only be waived for
24 not-for-profit hospitals operating as a freestanding cancer
25 hospital that have contracted to provide services to members
26 served by at least 50% of the managed care organizations
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1 contracted with the Department. Such tax rates imposed on a
2 hospital shall be no more than 50% and no less than 25% of the
3 tax imposed on all other hospitals in this State unless
4 different rates are necessary to meet federal statistical
5 tests necessary for continued federal financial participation.
6 Upon federal approval of such a waiver, other tax rates
7 imposed under this Article shall be adjusted to ensure budget
8 neutrality.
9 (b) (Blank).
10 (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
11 portion of State fiscal year 2012, beginning June 10, 2012
12 through June 30, 2012, and for State fiscal years 2013 through
13 2018, or as provided in Section 5A-16, an annual assessment on
14 outpatient services is imposed on each hospital provider in an
15 amount equal to .008766 multiplied by the hospital's
16 outpatient gross revenue, provided, however, that the amount
17 of .008766 shall be increased by a uniform percentage to
18 generate an amount equal to 25% of the State share of the
19 payments authorized under Section 5A-12.5, with such increase
20 only taking effect upon the date that a State share for such
21 payments is required under federal law. For the period
22 beginning June 10, 2012 through June 30, 2012, the annual
23 assessment on outpatient services shall be prorated by
24 multiplying the assessment amount by a fraction, the numerator
25 of which is 21 days and the denominator of which is 365 days.
26 For the period of April through June 2015, the amount of
SB2437 Enrolled - 219 - LRB104 10548 KTG 20624 b
1 .008766 used to calculate the assessment under this paragraph
2 shall, by emergency rule under subsection (s) of Section 5-45
3 of the Illinois Administrative Procedure Act, be increased by
4 a uniform percentage to generate $6,750,000 in the aggregate
5 for that period from all hospitals subject to the annual
6 assessment under this paragraph.
7 (2) In addition to any other assessments imposed under
8 this Article, effective July 1, 2016 and semi-annually
9 thereafter through June 2018, in addition to any federally
10 required State share as authorized under paragraph (1), the
11 amount of .008766 shall be increased by a uniform percentage
12 to generate an amount equal to 25% of the ACA Assessment
13 Adjustment, as defined in subsection (b-6) of this Section.
14 For the portion of State fiscal year 2012, beginning June
15 10, 2012 through June 30, 2012, and State fiscal years 2013
16 through 2018, or as provided in Section 5A-16, a hospital's
17 outpatient gross revenue shall be determined using the most
18 recent data available from each hospital's 2009 Medicare cost
19 report as contained in the Healthcare Cost Report Information
20 System file, for the quarter ending on June 30, 2011, without
21 regard to any subsequent adjustments or changes to such data.
22 If a hospital's 2009 Medicare cost report is not contained in
23 the Healthcare Cost Report Information System, then the
24 Department may obtain the hospital provider's outpatient gross
25 revenue from any source available, including, but not limited
26 to, records maintained by the hospital provider, which may be
SB2437 Enrolled - 220 - LRB104 10548 KTG 20624 b
1 inspected at all times during business hours of the day by the
2 Department or its duly authorized agents and employees.
3 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
4 fiscal years 2019 and 2020, an annual assessment on outpatient
5 services is imposed on each hospital provider in an amount
6 equal to .01358 multiplied by the hospital's outpatient gross
7 revenue. For State fiscal years 2019 and 2020, a hospital's
8 outpatient gross revenue shall be determined using the most
9 recent data available from each hospital's 2015 Medicare cost
10 report as contained in the Healthcare Cost Report Information
11 System file, for the quarter ending on March 31, 2017, without
12 regard to any subsequent adjustments or changes to such data.
13 If a hospital's 2015 Medicare cost report is not contained in
14 the Healthcare Cost Report Information System, then the
15 Department may obtain the hospital provider's outpatient gross
16 revenue from any source available, including, but not limited
17 to, records maintained by the hospital provider, which may be
18 inspected at all times during business hours of the day by the
19 Department or its duly authorized agents and employees.
20 Notwithstanding any other provision in this Article, for a
21 hospital provider that did not have a 2015 Medicare cost
22 report, but paid an assessment in State fiscal year 2018 on the
23 basis of hypothetical data, that assessment amount shall be
24 used for State fiscal years 2019 and 2020.
25 (4) Subject to Sections 5A-3 and 5A-10 and to subsection
26 (b-8), for the period of July 1, 2020 through December 31, 2020
SB2437 Enrolled - 221 - LRB104 10548 KTG 20624 b
1 and calendar years 2021 through 2026, an annual assessment on
2 outpatient services is imposed on each hospital provider in an
3 amount equal to .01525 multiplied by the hospital's outpatient
4 gross revenue, provided however: (i) for the period of July 1,
5 2020 through December 31, 2020, the assessment shall be equal
6 to 50% of the annual amount; and (ii) the amount of .01525
7 shall be retroactively adjusted by a uniform percentage to
8 generate an amount equal to 50% of the Assessment Adjustment,
9 as defined in subsection (b-7). For the period of July 1, 2020
10 through December 31, 2020 and calendar years 2021 through
11 2026, a hospital's outpatient gross revenue shall be
12 determined using the most recent data available from each
13 hospital's 2015 Medicare cost report as contained in the
14 Healthcare Cost Report Information System file, for the
15 quarter ending on March 31, 2017, without regard to any
16 subsequent adjustments or changes to such data. If a
17 hospital's 2015 Medicare cost report is not contained in the
18 Healthcare Cost Report Information System, then the Illinois
19 Department may obtain the hospital provider's outpatient
20 revenue data from any source available, including, but not
21 limited to, records maintained by the hospital provider, which
22 may be inspected at all times during business hours of the day
23 by the Illinois Department or its duly authorized agents and
24 employees. Should the change in the assessment methodology
25 above for fiscal years 2021 through calendar year 2022 not be
26 approved prior to July 1, 2020, the assessment and payments
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1 under this Article in effect for fiscal year 2020 shall remain
2 in place until the new assessment is approved. If the change in
3 the assessment methodology above for July 1, 2020 through
4 December 31, 2022, is approved after June 30, 2020, it shall
5 have a retroactive effective date of July 1, 2020, subject to
6 federal approval and provided that the payments authorized
7 under Section 12A-7 have the same effective date as the new
8 assessment methodology. In giving retroactive effect to the
9 assessment approved after June 30, 2020, credit toward the new
10 assessment shall be given for any payments of the previous
11 assessment for periods after June 30, 2020. Notwithstanding
12 any other provision of this Article, for a hospital provider
13 that did not have a 2015 Medicare cost report, but paid an
14 assessment in State Fiscal Year 2020 on the basis of
15 hypothetical data, the data that was the basis for the 2020
16 assessment shall be used to calculate the assessment under
17 this paragraph until December 31, 2023. Beginning July 1, 2022
18 and through December 31, 2024, a safety-net hospital that had
19 a change of ownership in calendar year 2021, and whose
20 inpatient utilization had decreased by 90% from the prior year
21 and prior to the change of ownership, may be eligible to pay a
22 tax based on hypothetical data based on a determination of
23 financial distress by the Department.
24 (6) For calendar year 2026, and for each year thereafter
25 in which a tax is imposed under this Section, the Department
26 may seek to obtain a waiver from the federal Centers for
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1 Medicare and Medicaid Services of the uniformity requirements
2 in place for the tax imposed under this Section, provided that
3 such waiver request does not risk the assessment imposed or
4 payments authorized under this Section from continuing. Such
5 uniformity requirements shall only be waived for
6 not-for-profit hospitals operating as a freestanding cancer
7 hospital that have contracted to provide services to members
8 served by at least 50% of the managed care organizations
9 contracted with the Department. Such tax rates imposed on a
10 hospital shall be no more than 50% and no less than 25% of the
11 tax imposed on all other hospitals in this State unless
12 different rates are necessary to meet federal statistical
13 tests necessary for continued federal financial participation.
14 Upon federal approval of such a waiver, other tax rates
15 imposed under this Article shall be adjusted to ensure budget
16 neutrality.
17 (b-6)(1) As used in this Section, "ACA Assessment
18 Adjustment" means:
19 (A) For the period of July 1, 2016 through December
20 31, 2016, the product of .19125 multiplied by the sum of
21 the fee-for-service payments to hospitals as authorized
22 under Section 5A-12.5 and the adjustments authorized under
23 subsection (t) of Section 5A-12.2 to managed care
24 organizations for hospital services due and payable in the
25 month of April 2016 multiplied by 6.
26 (B) For the period of January 1, 2017 through June 30,
SB2437 Enrolled - 224 - LRB104 10548 KTG 20624 b
1 2017, the product of .19125 multiplied by the sum of the
2 fee-for-service payments to hospitals as authorized under
3 Section 5A-12.5 and the adjustments authorized under
4 subsection (t) of Section 5A-12.2 to managed care
5 organizations for hospital services due and payable in the
6 month of October 2016 multiplied by 6, except that the
7 amount calculated under this subparagraph (B) shall be
8 adjusted, either positively or negatively, to account for
9 the difference between the actual payments issued under
10 Section 5A-12.5 for the period beginning July 1, 2016
11 through December 31, 2016 and the estimated payments due
12 and payable in the month of April 2016 multiplied by 6 as
13 described in subparagraph (A).
14 (C) For the period of July 1, 2017 through December
15 31, 2017, the product of .19125 multiplied by the sum of
16 the fee-for-service payments to hospitals as authorized
17 under Section 5A-12.5 and the adjustments authorized under
18 subsection (t) of Section 5A-12.2 to managed care
19 organizations for hospital services due and payable in the
20 month of April 2017 multiplied by 6, except that the
21 amount calculated under this subparagraph (C) shall be
22 adjusted, either positively or negatively, to account for
23 the difference between the actual payments issued under
24 Section 5A-12.5 for the period beginning January 1, 2017
25 through June 30, 2017 and the estimated payments due and
26 payable in the month of October 2016 multiplied by 6 as
SB2437 Enrolled - 225 - LRB104 10548 KTG 20624 b
1 described in subparagraph (B).
2 (D) For the period of January 1, 2018 through June 30,
3 2018, the product of .19125 multiplied by the sum of the
4 fee-for-service payments to hospitals as authorized under
5 Section 5A-12.5 and the adjustments authorized under
6 subsection (t) of Section 5A-12.2 to managed care
7 organizations for hospital services due and payable in the
8 month of October 2017 multiplied by 6, except that:
9 (i) the amount calculated under this subparagraph
10 (D) shall be adjusted, either positively or
11 negatively, to account for the difference between the
12 actual payments issued under Section 5A-12.5 for the
13 period of July 1, 2017 through December 31, 2017 and
14 the estimated payments due and payable in the month of
15 April 2017 multiplied by 6 as described in
16 subparagraph (C); and
17 (ii) the amount calculated under this subparagraph
18 (D) shall be adjusted to include the product of .19125
19 multiplied by the sum of the fee-for-service payments,
20 if any, estimated to be paid to hospitals under
21 subsection (b) of Section 5A-12.5.
22 (2) The Department shall complete and apply a final
23 reconciliation of the ACA Assessment Adjustment prior to June
24 30, 2018 to account for:
25 (A) any differences between the actual payments issued
26 or scheduled to be issued prior to June 30, 2018 as
SB2437 Enrolled - 226 - LRB104 10548 KTG 20624 b
1 authorized in Section 5A-12.5 for the period of January 1,
2 2018 through June 30, 2018 and the estimated payments due
3 and payable in the month of October 2017 multiplied by 6 as
4 described in subparagraph (D); and
5 (B) any difference between the estimated
6 fee-for-service payments under subsection (b) of Section
7 5A-12.5 and the amount of such payments that are actually
8 scheduled to be paid.
9 The Department shall notify hospitals of any additional
10 amounts owed or reduction credits to be applied to the June
11 2018 ACA Assessment Adjustment. This is to be considered the
12 final reconciliation for the ACA Assessment Adjustment.
13 (3) Notwithstanding any other provision of this Section,
14 if for any reason the scheduled payments under subsection (b)
15 of Section 5A-12.5 are not issued in full by the final day of
16 the period authorized under subsection (b) of Section 5A-12.5,
17 funds collected from each hospital pursuant to subparagraph
18 (D) of paragraph (1) and pursuant to paragraph (2),
19 attributable to the scheduled payments authorized under
20 subsection (b) of Section 5A-12.5 that are not issued in full
21 by the final day of the period attributable to each payment
22 authorized under subsection (b) of Section 5A-12.5, shall be
23 refunded.
24 (4) The increases authorized under paragraph (2) of
25 subsection (a) and paragraph (2) of subsection (b-5) shall be
26 limited to the federally required State share of the total
SB2437 Enrolled - 227 - LRB104 10548 KTG 20624 b
1 payments authorized under Section 5A-12.5 if the sum of such
2 payments yields an annualized amount equal to or less than
3 $450,000,000, or if the adjustments authorized under
4 subsection (t) of Section 5A-12.2 are found not to be
5 actuarially sound; however, this limitation shall not apply to
6 the fee-for-service payments described in subsection (b) of
7 Section 5A-12.5.
8 (b-7)(1) As used in this Section, "Assessment Adjustment"
9 means:
10 (A) For the period of July 1, 2020 through December
11 31, 2020, the product of .3853 multiplied by the total of
12 the actual payments made under subsections (c) through (k)
13 of Section 5A-12.7 attributable to the period, less the
14 total of the assessment imposed under subsections (a) and
15 (b-5) of this Section for the period.
16 (B) For each calendar quarter beginning January 1,
17 2021 through December 31, 2022, the product of .3853
18 multiplied by the total of the actual payments made under
19 subsections (c) through (k) of Section 5A-12.7
20 attributable to the period, less the total of the
21 assessment imposed under subsections (a) and (b-5) of this
22 Section for the period.
23 (C) Beginning on January 1, 2023, and each subsequent
24 July 1 and January 1, the product of .3853 multiplied by
25 the total of the actual payments made under subsections
26 (c) through (j) of Section 5A-12.7 attributable to the
SB2437 Enrolled - 228 - LRB104 10548 KTG 20624 b
1 6-month period immediately preceding the period to which
2 the adjustment applies, less the total of the assessment
3 imposed under subsections (a) and (b-5) of this Section
4 for the 6-month period immediately preceding the period to
5 which the adjustment applies.
6 (2) The Department shall calculate and notify each
7 hospital of the total Assessment Adjustment and any additional
8 assessment owed by the hospital or refund owed to the hospital
9 on either a semi-annual or annual basis. Such notice shall be
10 issued at least 30 days prior to any period in which the
11 assessment will be adjusted. Any additional assessment owed by
12 the hospital or refund owed to the hospital shall be uniformly
13 applied to the assessment owed by the hospital in monthly
14 installments for the subsequent semi-annual period or calendar
15 year. If no assessment is owed in the subsequent year, any
16 amount owed by the hospital or refund due to the hospital,
17 shall be paid in a lump sum.
18 (3) The Department shall publish all details of the
19 Assessment Adjustment calculation performed each year on its
20 website within 30 days of completing the calculation, and also
21 submit the details of the Assessment Adjustment calculation as
22 part of the Department's annual report to the General
23 Assembly.
24 (b-8) Notwithstanding any other provision of this Article,
25 the Department shall reduce the assessments imposed on each
26 hospital under subsections (a) and (b-5) by the uniform
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1 percentage necessary to reduce the total assessment imposed on
2 all hospitals by an aggregate amount of $240,000,000, with
3 such reduction being applied by June 30, 2022. The assessment
4 reduction required for each hospital under this subsection
5 shall be forever waived, forgiven, and released by the
6 Department.
7 (c) (Blank).
8 (d) Notwithstanding any of the other provisions of this
9 Section, the Department is authorized to adopt rules to reduce
10 the rate of any annual assessment imposed under this Section,
11 as authorized by Section 5-46.2 of the Illinois Administrative
12 Procedure Act.
13 (e) Notwithstanding any other provision of this Section,
14 any plan providing for an assessment on a hospital provider as
15 a permissible tax under Title XIX of the federal Social
16 Security Act and Medicaid-eligible payments to hospital
17 providers from the revenues derived from that assessment shall
18 be reviewed by the Illinois Department of Healthcare and
19 Family Services, as the Single State Medicaid Agency required
20 by federal law, to determine whether those assessments and
21 hospital provider payments meet federal Medicaid standards. If
22 the Department determines that the elements of the plan may
23 meet federal Medicaid standards and a related State Medicaid
24 Plan Amendment is prepared in a manner and form suitable for
25 submission, that State Plan Amendment shall be submitted in a
26 timely manner for review by the Centers for Medicare and
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1 Medicaid Services of the United States Department of Health
2 and Human Services and subject to approval by the Centers for
3 Medicare and Medicaid Services of the United States Department
4 of Health and Human Services. No such plan shall become
5 effective without approval by the Illinois General Assembly by
6 the enactment into law of related legislation. Notwithstanding
7 any other provision of this Section, the Department is
8 authorized to adopt rules to reduce the rate of any annual
9 assessment imposed under this Section. Any such rules may be
10 adopted by the Department under Section 5-50 of the Illinois
11 Administrative Procedure Act.
12 (Source: P.A. 102-886, eff. 5-17-22; 103-102, eff. 1-1-24.)
13 ARTICLE 800.
14 Section 800-95. No acceleration or delay. Where this Act
15 makes changes in a statute that is represented in this Act by
16 text that is not yet or no longer in effect (for example, a
17 Section represented by multiple versions), the use of that
18 text does not accelerate or delay the taking effect of (i) the
19 changes made by this Act or (ii) provisions derived from any
20 other Public Act.
21 ARTICLE 999.
22 Section 999-99. Effective date. This Act takes effect upon
23 becoming law, except that Article 10 takes effect January 1,
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1 2026.Every fact on this page links to its source, starting with the official bill record.