Shown verbatim: the complete text as captured from the official PDF posted by the Illinois General Assembly, fetched 2026-09-25. Page and line markers are part of the official record; nothing is edited or removed. This is the current version. The official bill page.
Large document: the complete text runs about 137,000 words on this one page, so it can take a moment to load and render.
SB3365 Enrolled LRB104 18483 SSS 31925 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 2-5. The Illinois Public Aid Code is amended by
6 changing Section 5-5 as follows:
7 (305 ILCS 5/5-5)
8 Sec. 5-5. Medical services. The Illinois Department, by
9 rule, shall determine the quantity and quality of and the rate
10 of reimbursement for the medical assistance for which payment
11 will be authorized, and the medical services to be provided,
12 which may include all or part of the following: (1) inpatient
13 hospital services; (2) outpatient hospital services; (3) other
14 laboratory and X-ray services; (4) skilled nursing home
15 services; (5) physicians' services whether furnished in the
16 office, the patient's home, a hospital, a skilled nursing
17 home, or elsewhere; (6) medical care, or any other type of
18 remedial care furnished by licensed practitioners; (7) home
19 health care services; (8) private duty nursing service; (9)
20 clinic services; (10) dental services, including prevention
21 and treatment of periodontal disease and dental caries disease
22 for pregnant individuals, provided by an individual licensed
SB3365 Enrolled -2- LRB104 18483 SSS 31925 b
1 to practice dentistry or dental surgery; for purposes of this
2 item (10), "dental services" means diagnostic, preventive, or
3 corrective procedures provided by or under the supervision of
4 a dentist in the practice of his or her profession; (11)
5 physical therapy and related services; (12) prescribed drugs,
6 dentures, and prosthetic devices; and eyeglasses prescribed by
7 a physician skilled in the diseases of the eye, or by an
8 optometrist, whichever the person may select; (13) other
9 diagnostic, screening, preventive, and rehabilitative
10 services, including to ensure that the individual's need for
11 intervention or treatment of mental disorders or substance use
12 disorders or co-occurring mental health and substance use
13 disorders is determined using a uniform screening, assessment,
14 and evaluation process inclusive of criteria, for children and
15 adults; for purposes of this item (13), a uniform screening,
16 assessment, and evaluation process refers to a process that
17 includes an appropriate evaluation and, as warranted, a
18 referral; "uniform" does not mean the use of a singular
19 instrument, tool, or process that all must utilize; (14)
20 transportation and such other expenses as may be necessary;
21 (15) medical treatment of sexual assault survivors, as defined
22 in Section 1a of the Sexual Assault Survivors Emergency
23 Treatment Act, for injuries sustained as a result of the
24 sexual assault, including examinations and laboratory tests to
25 discover evidence which may be used in criminal proceedings
26 arising from the sexual assault; (16) the diagnosis and
SB3365 Enrolled -3- LRB104 18483 SSS 31925 b
1 treatment of sickle cell disease anemia; (16.5) services
2 performed by a chiropractic physician licensed under the
3 Medical Practice Act of 1987 and acting within the scope of his
4 or her license, including, but not limited to, chiropractic
5 manipulative treatment; and (17) any other medical care, and
6 any other type of remedial care recognized under the laws of
7 this State. The term "any other type of remedial care" shall
8 include nursing care and nursing home service for persons who
9 rely on treatment by spiritual means alone through prayer for
10 healing.
11 Notwithstanding any other provision of this Section, a
12 comprehensive tobacco use cessation program that includes
13 purchasing prescription drugs or prescription medical devices
14 approved by the Food and Drug Administration shall be covered
15 under the medical assistance program under this Article for
16 persons who are otherwise eligible for assistance under this
17 Article.
18 Notwithstanding any other provision of this Code,
19 reproductive health care that is otherwise legal in Illinois
20 shall be covered under the medical assistance program for
21 persons who are otherwise eligible for medical assistance
22 under this Article.
23 Notwithstanding any other provision of this Section, all
24 tobacco cessation medications approved by the United States
25 Food and Drug Administration and all individual and group
26 tobacco cessation counseling services and telephone-based
SB3365 Enrolled -4- LRB104 18483 SSS 31925 b
1 counseling services and tobacco cessation medications provided
2 through the Illinois Tobacco Quitline shall be covered under
3 the medical assistance program for persons who are otherwise
4 eligible for assistance under this Article. The Department
5 shall comply with all federal requirements necessary to obtain
6 federal financial participation, as specified in 42 CFR
7 433.15(b)(7), for telephone-based counseling services provided
8 through the Illinois Tobacco Quitline, including, but not
9 limited to: (i) entering into a memorandum of understanding or
10 interagency agreement with the Department of Public Health, as
11 administrator of the Illinois Tobacco Quitline; and (ii)
12 developing a cost allocation plan for Medicaid-allowable
13 Illinois Tobacco Quitline services in accordance with 45 CFR
14 95.507. The Department shall submit the memorandum of
15 understanding or interagency agreement, the cost allocation
16 plan, and all other necessary documentation to the Centers for
17 Medicare and Medicaid Services for review and approval.
18 Coverage under this paragraph shall be contingent upon federal
19 approval.
20 Notwithstanding any other provision of this Code, the
21 Illinois Department may not require, as a condition of payment
22 for any laboratory test authorized under this Article, that a
23 physician's handwritten signature appear on the laboratory
24 test order form. The Illinois Department may, however, impose
25 other appropriate requirements regarding laboratory test order
26 documentation.
SB3365 Enrolled -5- LRB104 18483 SSS 31925 b
1 Upon receipt of federal approval of an amendment to the
2 Illinois Title XIX State Plan for this purpose, the Department
3 shall authorize the Chicago Public Schools (CPS) to procure a
4 vendor or vendors to manufacture eyeglasses for individuals
5 enrolled in a school within the CPS system. CPS shall ensure
6 that its vendor or vendors are enrolled as providers in the
7 medical assistance program and in any capitated Medicaid
8 managed care entity (MCE) serving individuals enrolled in a
9 school within the CPS system. Under any contract procured
10 under this provision, the vendor or vendors must serve only
11 individuals enrolled in a school within the CPS system. Claims
12 for services provided by CPS's vendor or vendors to recipients
13 of benefits in the medical assistance program under this Code,
14 the Children's Health Insurance Program, or the Covering ALL
15 KIDS Health Insurance Program shall be submitted to the
16 Department or the MCE in which the individual is enrolled for
17 payment and shall be reimbursed at the Department's or the
18 MCE's established rates or rate methodologies for eyeglasses.
19 On and after July 1, 2012, the Department of Healthcare
20 and Family Services may provide the following services to
21 persons eligible for assistance under this Article who are
22 participating in education, training or employment programs
23 operated by the Department of Human Services as successor to
24 the Department of Public Aid:
25 (1) dental services provided by or under the
26 supervision of a dentist; and
SB3365 Enrolled -6- LRB104 18483 SSS 31925 b
1 (2) eyeglasses prescribed by a physician skilled in
2 the diseases of the eye, or by an optometrist, whichever
3 the person may select.
4 On and after July 1, 2018, the Department of Healthcare
5 and Family Services shall provide dental services to any adult
6 who is otherwise eligible for assistance under the medical
7 assistance program. As used in this paragraph, "dental
8 services" means diagnostic, preventative, restorative, or
9 corrective procedures, including procedures and services for
10 the prevention and treatment of periodontal disease and dental
11 caries disease, provided by an individual who is licensed to
12 practice dentistry or dental surgery or who is under the
13 supervision of a dentist in the practice of his or her
14 profession.
15 On and after July 1, 2018, targeted dental services, as
16 set forth in Exhibit D of the Consent Decree entered by the
17 United States District Court for the Northern District of
18 Illinois, Eastern Division, in the matter of Memisovski v.
19 Maram, Case No. 92 C 1982, that are provided to adults under
20 the medical assistance program shall be established at no less
21 than the rates set forth in the "New Rate" column in Exhibit D
22 of the Consent Decree for targeted dental services that are
23 provided to persons under the age of 18 under the medical
24 assistance program.
25 Subject to federal approval, on and after January 1, 2025,
26 the rates paid for sedation evaluation and the provision of
SB3365 Enrolled -7- LRB104 18483 SSS 31925 b
1 deep sedation and intravenous sedation for the purpose of
2 dental services shall be increased by 33% above the rates in
3 effect on December 31, 2024. The rates paid for nitrous oxide
4 sedation shall not be impacted by this paragraph and shall
5 remain the same as the rates in effect on December 31, 2024.
6 Notwithstanding any other provision of this Code and
7 subject to federal approval, the Department may adopt rules to
8 allow a dentist who is volunteering his or her service at no
9 cost to render dental services through an enrolled
10 not-for-profit health clinic without the dentist personally
11 enrolling as a participating provider in the medical
12 assistance program. A not-for-profit health clinic shall
13 include a public health clinic or Federally Qualified Health
14 Center or other enrolled provider, as determined by the
15 Department, through which dental services covered under this
16 Section are performed. The Department shall establish a
17 process for payment of claims for reimbursement for covered
18 dental services rendered under this provision.
19 Subject to appropriation and to federal approval, the
20 Department shall file administrative rules updating the
21 Handicapping Labio-Lingual Deviation orthodontic scoring tool
22 by January 1, 2025, or as soon as practicable.
23 On and after January 1, 2022, the Department of Healthcare
24 and Family Services shall administer and regulate a
25 school-based dental program that allows for the out-of-office
26 delivery of preventative dental services in a school setting
SB3365 Enrolled -8- LRB104 18483 SSS 31925 b
1 to children under 19 years of age. The Department shall
2 establish, by rule, guidelines for participation by providers
3 and set requirements for follow-up referral care based on the
4 requirements established in the Dental Office Reference Manual
5 published by the Department that establishes the requirements
6 for dentists participating in the All Kids Dental School
7 Program. Every effort shall be made by the Department when
8 developing the program requirements to consider the different
9 geographic differences of both urban and rural areas of the
10 State for initial treatment and necessary follow-up care. No
11 provider shall be charged a fee by any unit of local government
12 to participate in the school-based dental program administered
13 by the Department. Nothing in this paragraph shall be
14 construed to limit or preempt a home rule unit's or school
15 district's authority to establish, change, or administer a
16 school-based dental program in addition to, or independent of,
17 the school-based dental program administered by the
18 Department.
19 The Illinois Department, by rule, may distinguish and
20 classify the medical services to be provided only in
21 accordance with the classes of persons designated in Section
22 5-2.
23 The Department of Healthcare and Family Services must
24 provide coverage and reimbursement for amino acid-based
25 elemental formulas, regardless of delivery method, for the
26 diagnosis and treatment of (i) eosinophilic disorders and (ii)
SB3365 Enrolled -9- LRB104 18483 SSS 31925 b
1 short bowel syndrome when the prescribing physician has issued
2 a written order stating that the amino acid-based elemental
3 formula is medically necessary.
4 The Illinois Department shall authorize the provision of,
5 and shall authorize payment for, screening by low-dose
6 mammography for the presence of occult breast cancer for
7 individuals 35 years of age or older who are eligible for
8 medical assistance under this Article, as follows:
9 (A) A baseline mammogram for individuals 35 to 39
10 years of age.
11 (B) An annual mammogram for individuals 40 years of
12 age or older.
13 (C) A mammogram at the age and intervals considered
14 medically necessary by the individual's health care
15 provider for individuals under 40 years of age and having
16 a family history of breast cancer, prior personal history
17 of breast cancer, positive genetic testing, or other risk
18 factors.
19 (D) A comprehensive ultrasound screening and MRI of an
20 entire breast or breasts if a mammogram demonstrates
21 heterogeneous or dense breast tissue or when medically
22 necessary as determined by a physician licensed to
23 practice medicine in all of its branches.
24 (E) A screening MRI when medically necessary, as
25 determined by a physician licensed to practice medicine in
26 all of its branches.
SB3365 Enrolled - 10 - LRB104 18483 SSS 31925 b
1 (F) A diagnostic mammogram when medically necessary,
2 as determined by a physician licensed to practice medicine
3 in all its branches, advanced practice registered nurse,
4 or physician assistant.
5 (G) Molecular breast imaging (MBI) and MRI of an
6 entire breast or breasts if a mammogram demonstrates
7 heterogeneous or dense breast tissue or when medically
8 necessary as determined by a physician licensed to
9 practice medicine in all of its branches, advanced
10 practice registered nurse, or physician assistant.
11 The Department shall not impose a deductible, coinsurance,
12 copayment, or any other cost-sharing requirement on the
13 coverage provided under this paragraph; except that this
14 sentence does not apply to coverage of diagnostic mammograms
15 to the extent such coverage would disqualify a high-deductible
16 health plan from eligibility for a health savings account
17 pursuant to Section 223 of the Internal Revenue Code (26
18 U.S.C. 223).
19 All screenings shall include a physical breast exam,
20 instruction on self-examination and information regarding the
21 frequency of self-examination and its value as a preventative
22 tool.
23 For purposes of this Section:
24 "Diagnostic mammogram" means a mammogram obtained using
25 diagnostic mammography.
26 "Diagnostic mammography" means a method of screening that
SB3365 Enrolled - 11 - LRB104 18483 SSS 31925 b
1 is designed to evaluate an abnormality in a breast, including
2 an abnormality seen or suspected on a screening mammogram or a
3 subjective or objective abnormality otherwise detected in the
4 breast.
5 "Low-dose mammography" means the x-ray examination of the
6 breast using equipment dedicated specifically for mammography,
7 including the x-ray tube, filter, compression device, and
8 image receptor, with an average radiation exposure delivery of
9 less than one rad per breast for 2 views of an average size
10 breast. The term also includes digital mammography and
11 includes breast tomosynthesis.
12 "Breast tomosynthesis" means a radiologic procedure that
13 involves the acquisition of projection images over the
14 stationary breast to produce cross-sectional digital
15 three-dimensional images of the breast.
16 If, at any time, the Secretary of the United States
17 Department of Health and Human Services, or its successor
18 agency, promulgates rules or regulations to be published in
19 the Federal Register or publishes a comment in the Federal
20 Register or issues an opinion, guidance, or other action that
21 would require the State, pursuant to any provision of the
22 Patient Protection and Affordable Care Act (Public Law
23 111-148), including, but not limited to, 42 U.S.C.
24 18031(d)(3)(B) or any successor provision, to defray the cost
25 of any coverage for breast tomosynthesis outlined in this
26 paragraph, then the requirement that an insurer cover breast
SB3365 Enrolled - 12 - LRB104 18483 SSS 31925 b
1 tomosynthesis is inoperative other than any such coverage
2 authorized under Section 1902 of the Social Security Act, 42
3 U.S.C. 1396a, and the State shall not assume any obligation
4 for the cost of coverage for breast tomosynthesis set forth in
5 this paragraph.
6 On and after January 1, 2016, the Department shall ensure
7 that all networks of care for adult clients of the Department
8 include access to at least one breast imaging Center of
9 Imaging Excellence as certified by the American College of
10 Radiology.
11 On and after January 1, 2012, providers participating in a
12 quality improvement program approved by the Department shall
13 be reimbursed for screening and diagnostic mammography at the
14 same rate as the Medicare program's rates, including the
15 increased reimbursement for digital mammography and, after
16 January 1, 2023 (the effective date of Public Act 102-1018),
17 breast tomosynthesis.
18 The Department shall convene an expert panel including
19 representatives of hospitals, free-standing mammography
20 facilities, and doctors, including radiologists, to establish
21 quality standards for mammography.
22 On and after January 1, 2017, providers participating in a
23 breast cancer treatment quality improvement program approved
24 by the Department shall be reimbursed for breast cancer
25 treatment at a rate that is no lower than 95% of the Medicare
26 program's rates for the data elements included in the breast
SB3365 Enrolled - 13 - LRB104 18483 SSS 31925 b
1 cancer treatment quality program.
2 The Department shall convene an expert panel, including
3 representatives of hospitals, free-standing breast cancer
4 treatment centers, breast cancer quality organizations, and
5 doctors, including radiologists that are trained in all forms
6 of FDA-approved breast imaging technologies, breast surgeons,
7 reconstructive breast surgeons, oncologists, and primary care
8 providers to establish quality standards for breast cancer
9 treatment.
10 Subject to federal approval, the Department shall
11 establish a rate methodology for mammography at federally
12 qualified health centers and other encounter-rate clinics.
13 These clinics or centers may also collaborate with other
14 hospital-based mammography facilities. By January 1, 2016, the
15 Department shall report to the General Assembly on the status
16 of the provision set forth in this paragraph.
17 The Department shall establish a methodology to remind
18 individuals who are age-appropriate for screening mammography,
19 but who have not received a mammogram within the previous 18
20 months, of the importance and benefit of screening
21 mammography. The Department shall work with experts in breast
22 cancer outreach and patient navigation to optimize these
23 reminders and shall establish a methodology for evaluating
24 their effectiveness and modifying the methodology based on the
25 evaluation.
26 The Department shall establish a performance goal for
SB3365 Enrolled - 14 - LRB104 18483 SSS 31925 b
1 primary care providers with respect to their female patients
2 over age 40 receiving an annual mammogram. This performance
3 goal shall be used to provide additional reimbursement in the
4 form of a quality performance bonus to primary care providers
5 who meet that goal.
6 The Department shall devise a means of case-managing or
7 patient navigation for beneficiaries diagnosed with breast
8 cancer. This program shall initially operate as a pilot
9 program in areas of the State with the highest incidence of
10 mortality related to breast cancer. At least one pilot program
11 site shall be in the metropolitan Chicago area and at least one
12 site shall be outside the metropolitan Chicago area. On or
13 after July 1, 2016, the pilot program shall be expanded to
14 include one site in western Illinois, one site in southern
15 Illinois, one site in central Illinois, and 4 sites within
16 metropolitan Chicago. An evaluation of the pilot program shall
17 be carried out measuring health outcomes and cost of care for
18 those served by the pilot program compared to similarly
19 situated patients who are not served by the pilot program.
20 The Department shall require all networks of care to
21 develop a means either internally or by contract with experts
22 in navigation and community outreach to navigate cancer
23 patients to comprehensive care in a timely fashion. The
24 Department shall require all networks of care to include
25 access for patients diagnosed with cancer to at least one
26 academic commission on cancer-accredited cancer program as an
SB3365 Enrolled - 15 - LRB104 18483 SSS 31925 b
1 in-network covered benefit.
2 The Department shall provide coverage and reimbursement
3 for a human papillomavirus (HPV) vaccine that is approved for
4 marketing by the federal Food and Drug Administration for all
5 persons between the ages of 9 and 45. Subject to federal
6 approval, the Department shall provide coverage and
7 reimbursement for a human papillomavirus (HPV) vaccine for
8 persons of the age of 46 and above who have been diagnosed with
9 cervical dysplasia with a high risk of recurrence or
10 progression. The Department shall disallow any
11 preauthorization requirements for the administration of the
12 human papillomavirus (HPV) vaccine.
13 On or after July 1, 2022, individuals who are otherwise
14 eligible for medical assistance under this Article shall
15 receive coverage for perinatal depression screenings for the
16 12-month period beginning on the last day of their pregnancy.
17 Medical assistance coverage under this paragraph shall be
18 conditioned on the use of a screening instrument approved by
19 the Department.
20 Any medical or health care provider shall immediately
21 recommend, to any pregnant individual who is being provided
22 prenatal services and is suspected of having a substance use
23 disorder as defined in the Substance Use Disorder Act,
24 referral to a local substance use disorder treatment program
25 licensed by the Department of Human Services or to a licensed
26 hospital which provides substance abuse treatment services.
SB3365 Enrolled - 16 - LRB104 18483 SSS 31925 b
1 The Department of Healthcare and Family Services shall assure
2 coverage for the cost of treatment of the drug abuse or
3 addiction for pregnant recipients in accordance with the
4 Illinois Medicaid Program in conjunction with the Department
5 of Human Services.
6 All medical providers providing medical assistance to
7 pregnant individuals under this Code shall receive information
8 from the Department on the availability of services under any
9 program providing case management services for addicted
10 individuals, including information on appropriate referrals
11 for other social services that may be needed by addicted
12 individuals in addition to treatment for addiction.
13 The Illinois Department, in cooperation with the
14 Departments of Human Services (as successor to the Department
15 of Alcoholism and Substance Abuse) and Public Health, through
16 a public awareness campaign, may provide information
17 concerning treatment for alcoholism and drug abuse and
18 addiction, prenatal health care, and other pertinent programs
19 directed at reducing the number of drug-affected infants born
20 to recipients of medical assistance.
21 Neither the Department of Healthcare and Family Services
22 nor the Department of Human Services shall sanction the
23 recipient solely on the basis of the recipient's substance
24 abuse.
25 The Illinois Department shall establish such regulations
26 governing the dispensing of health services under this Article
SB3365 Enrolled - 17 - LRB104 18483 SSS 31925 b
1 as it shall deem appropriate. The Department should seek the
2 advice of formal professional advisory committees appointed by
3 the Director of the Illinois Department for the purpose of
4 providing regular advice on policy and administrative matters,
5 information dissemination and educational activities for
6 medical and health care providers, and consistency in
7 procedures to the Illinois Department.
8 The Illinois Department may develop and contract with
9 Partnerships of medical providers to arrange medical services
10 for persons eligible under Section 5-2 of this Code.
11 Implementation of this Section may be by demonstration
12 projects in certain geographic areas. The Partnership shall be
13 represented by a sponsor organization. The Department, by
14 rule, shall develop qualifications for sponsors of
15 Partnerships. Nothing in this Section shall be construed to
16 require that the sponsor organization be a medical
17 organization.
18 The sponsor must negotiate formal written contracts with
19 medical providers for physician services, inpatient and
20 outpatient hospital care, home health services, treatment for
21 alcoholism and substance abuse, and other services determined
22 necessary by the Illinois Department by rule for delivery by
23 Partnerships. Physician services must include prenatal and
24 obstetrical care. The Illinois Department shall reimburse
25 medical services delivered by Partnership providers to clients
26 in target areas according to provisions of this Article and
SB3365 Enrolled - 18 - LRB104 18483 SSS 31925 b
1 the Illinois Health Finance Reform Act, except that:
2 (1) Physicians participating in a Partnership and
3 providing certain services, which shall be determined by
4 the Illinois Department, to persons in areas covered by
5 the Partnership may receive an additional surcharge for
6 such services.
7 (2) The Department may elect to consider and negotiate
8 financial incentives to encourage the development of
9 Partnerships and the efficient delivery of medical care.
10 (3) Persons receiving medical services through
11 Partnerships may receive medical and case management
12 services above the level usually offered through the
13 medical assistance program.
14 Medical providers shall be required to meet certain
15 qualifications to participate in Partnerships to ensure the
16 delivery of high quality medical services. These
17 qualifications shall be determined by rule of the Illinois
18 Department and may be higher than qualifications for
19 participation in the medical assistance program. Partnership
20 sponsors may prescribe reasonable additional qualifications
21 for participation by medical providers, only with the prior
22 written approval of the Illinois Department.
23 Nothing in this Section shall limit the free choice of
24 practitioners, hospitals, and other providers of medical
25 services by clients. In order to ensure patient freedom of
26 choice, the Illinois Department shall immediately promulgate
SB3365 Enrolled - 19 - LRB104 18483 SSS 31925 b
1 all rules and take all other necessary actions so that
2 provided services may be accessed from therapeutically
3 certified optometrists to the full extent of the Illinois
4 Optometric Practice Act of 1987 without discriminating between
5 service providers.
6 The Department shall apply for a waiver from the United
7 States Health Care Financing Administration to allow for the
8 implementation of Partnerships under this Section.
9 The Illinois Department shall require health care
10 providers to maintain records that document the medical care
11 and services provided to recipients of Medical Assistance
12 under this Article. Such records must be retained for a period
13 of not less than 6 years from the date of service or as
14 provided by applicable State law, whichever period is longer,
15 except that if an audit is initiated within the required
16 retention period then the records must be retained until the
17 audit is completed and every exception is resolved. The
18 Illinois Department shall require health care providers to
19 make available, when authorized by the patient, in writing,
20 the medical records in a timely fashion to other health care
21 providers who are treating or serving persons eligible for
22 Medical Assistance under this Article. All dispensers of
23 medical services shall be required to maintain and retain
24 business and professional records sufficient to fully and
25 accurately document the nature, scope, details and receipt of
26 the health care provided to persons eligible for medical
SB3365 Enrolled - 20 - LRB104 18483 SSS 31925 b
1 assistance under this Code, in accordance with regulations
2 promulgated by the Illinois Department. The rules and
3 regulations shall require that proof of the receipt of
4 prescription drugs, dentures, prosthetic devices and
5 eyeglasses by eligible persons under this Section accompany
6 each claim for reimbursement submitted by the dispenser of
7 such medical services. No such claims for reimbursement shall
8 be approved for payment by the Illinois Department without
9 such proof of receipt, unless the Illinois Department shall
10 have put into effect and shall be operating a system of
11 post-payment audit and review which shall, on a sampling
12 basis, be deemed adequate by the Illinois Department to assure
13 that such drugs, dentures, prosthetic devices and eyeglasses
14 for which payment is being made are actually being received by
15 eligible recipients. Within 90 days after September 16, 1984
16 (the effective date of Public Act 83-1439), the Illinois
17 Department shall establish a current list of acquisition costs
18 for all prosthetic devices and any other items recognized as
19 medical equipment and supplies reimbursable under this Article
20 and shall update such list on a quarterly basis, except that
21 the acquisition costs of all prescription drugs shall be
22 updated no less frequently than every 30 days as required by
23 Section 5-5.12.
24 Notwithstanding any other law to the contrary, the
25 Illinois Department shall, within 365 days after July 22, 2013
26 (the effective date of Public Act 98-104), establish
SB3365 Enrolled - 21 - LRB104 18483 SSS 31925 b
1 procedures to permit skilled care facilities licensed under
2 the Nursing Home Care Act to submit monthly billing claims for
3 reimbursement purposes. Following development of these
4 procedures, the Department shall, by July 1, 2016, test the
5 viability of the new system and implement any necessary
6 operational or structural changes to its information
7 technology platforms in order to allow for the direct
8 acceptance and payment of nursing home claims.
9 Notwithstanding any other law to the contrary, the
10 Illinois Department shall, within 365 days after August 15,
11 2014 (the effective date of Public Act 98-963), establish
12 procedures to permit ID/DD facilities licensed under the ID/DD
13 Community Care Act and MC/DD facilities licensed under the
14 MC/DD Act to submit monthly billing claims for reimbursement
15 purposes. Following development of these procedures, the
16 Department shall have an additional 365 days to test the
17 viability of the new system and to ensure that any necessary
18 operational or structural changes to its information
19 technology platforms are implemented.
20 The Illinois Department shall require all dispensers of
21 medical services, other than an individual practitioner or
22 group of practitioners, desiring to participate in the Medical
23 Assistance program established under this Article to disclose
24 all financial, beneficial, ownership, equity, surety or other
25 interests in any and all firms, corporations, partnerships,
26 associations, business enterprises, joint ventures, agencies,
SB3365 Enrolled - 22 - LRB104 18483 SSS 31925 b
1 institutions or other legal entities providing any form of
2 health care services in this State under this Article.
3 The Illinois Department may require that all dispensers of
4 medical services desiring to participate in the medical
5 assistance program established under this Article disclose,
6 under such terms and conditions as the Illinois Department may
7 by rule establish, all inquiries from clients and attorneys
8 regarding medical bills paid by the Illinois Department, which
9 inquiries could indicate potential existence of claims or
10 liens for the Illinois Department.
11 Enrollment of a vendor shall be subject to a provisional
12 period and shall be conditional for one year. During the
13 period of conditional enrollment, the Department may terminate
14 the vendor's eligibility to participate in, or may disenroll
15 the vendor from, the medical assistance program without cause.
16 Unless otherwise specified, such termination of eligibility or
17 disenrollment is not subject to the Department's hearing
18 process. However, a disenrolled vendor may reapply without
19 penalty.
20 The Department has the discretion to limit the conditional
21 enrollment period for vendors based upon the category of risk
22 of the vendor.
23 Prior to enrollment and during the conditional enrollment
24 period in the medical assistance program, all vendors shall be
25 subject to enhanced oversight, screening, and review based on
26 the risk of fraud, waste, and abuse that is posed by the
SB3365 Enrolled - 23 - LRB104 18483 SSS 31925 b
1 category of risk of the vendor. The Illinois Department shall
2 establish the procedures for oversight, screening, and review,
3 which may include, but need not be limited to: criminal and
4 financial background checks; fingerprinting; license,
5 certification, and authorization verifications; unscheduled or
6 unannounced site visits; database checks; prepayment audit
7 reviews; audits; payment caps; payment suspensions; and other
8 screening as required by federal or State law.
9 The Department shall define or specify the following: (i)
10 by provider notice, the "category of risk of the vendor" for
11 each type of vendor, which shall take into account the level of
12 screening applicable to a particular category of vendor under
13 federal law and regulations; (ii) by rule or provider notice,
14 the maximum length of the conditional enrollment period for
15 each category of risk of the vendor; and (iii) by rule, the
16 hearing rights, if any, afforded to a vendor in each category
17 of risk of the vendor that is terminated or disenrolled during
18 the conditional enrollment period.
19 To be eligible for payment consideration, a vendor's
20 payment claim or bill, either as an initial claim or as a
21 resubmitted claim following prior rejection, must be received
22 by the Illinois Department, or its fiscal intermediary, no
23 later than 180 days after the latest date on the claim on which
24 medical goods or services were provided, with the following
25 exceptions:
26 (1) In the case of a provider whose enrollment is in
SB3365 Enrolled - 24 - LRB104 18483 SSS 31925 b
1 process by the Illinois Department, the 180-day period
2 shall not begin until the date on the written notice from
3 the Illinois Department that the provider enrollment is
4 complete.
5 (2) In the case of errors attributable to the Illinois
6 Department or any of its claims processing intermediaries
7 which result in an inability to receive, process, or
8 adjudicate a claim, the 180-day period shall not begin
9 until the provider has been notified of the error.
10 (3) In the case of a provider for whom the Illinois
11 Department initiates the monthly billing process.
12 (4) In the case of a provider operated by a unit of
13 local government with a population exceeding 3,000,000
14 when local government funds finance federal participation
15 for claims payments.
16 For claims for services rendered during a period for which
17 a recipient received retroactive eligibility, claims must be
18 filed within 180 days after the Department determines the
19 applicant is eligible. For claims for which the Illinois
20 Department is not the primary payer, claims must be submitted
21 to the Illinois Department within 180 days after the final
22 adjudication by the primary payer.
23 In the case of long term care facilities, within 120
24 calendar days of receipt by the facility of required
25 prescreening information, new admissions with associated
26 admission documents shall be submitted through the Medical
SB3365 Enrolled - 25 - LRB104 18483 SSS 31925 b
1 Electronic Data Interchange (MEDI) or the Recipient
2 Eligibility Verification (REV) System or shall be submitted
3 directly to the Department of Human Services using required
4 admission forms. Effective September 1, 2014, admission
5 documents, including all prescreening information, must be
6 submitted through MEDI or REV. Confirmation numbers assigned
7 to an accepted transaction shall be retained by a facility to
8 verify timely submittal. Once an admission transaction has
9 been completed, all resubmitted claims following prior
10 rejection are subject to receipt no later than 180 days after
11 the admission transaction has been completed.
12 Claims that are not submitted and received in compliance
13 with the foregoing requirements shall not be eligible for
14 payment under the medical assistance program, and the State
15 shall have no liability for payment of those claims.
16 To the extent consistent with applicable information and
17 privacy, security, and disclosure laws, State and federal
18 agencies and departments shall provide the Illinois Department
19 access to confidential and other information and data
20 necessary to perform eligibility and payment verifications and
21 other Illinois Department functions. This includes, but is not
22 limited to: information pertaining to licensure;
23 certification; earnings; immigration status; citizenship; wage
24 reporting; unearned and earned income; pension income;
25 employment; supplemental security income; social security
26 numbers; National Provider Identifier (NPI) numbers; the
SB3365 Enrolled - 26 - LRB104 18483 SSS 31925 b
1 National Practitioner Data Bank (NPDB); program and agency
2 exclusions; taxpayer identification numbers; tax delinquency;
3 corporate information; and death records.
4 The Illinois Department shall enter into agreements with
5 State agencies and departments, and is authorized to enter
6 into agreements with federal agencies and departments, under
7 which such agencies and departments shall share data necessary
8 for medical assistance program integrity functions and
9 oversight. The Illinois Department shall develop, in
10 cooperation with other State departments and agencies, and in
11 compliance with applicable federal laws and regulations,
12 appropriate and effective methods to share such data. At a
13 minimum, and to the extent necessary to provide data sharing,
14 the Illinois Department shall enter into agreements with State
15 agencies and departments, and is authorized to enter into
16 agreements with federal agencies and departments, including,
17 but not limited to: the Secretary of State; the Department of
18 Revenue; the Department of Public Health; the Department of
19 Human Services; and the Department of Financial and
20 Professional Regulation.
21 Beginning in fiscal year 2013, the Illinois Department
22 shall set forth a request for information to identify the
23 benefits of a pre-payment, post-adjudication, and post-edit
24 claims system with the goals of streamlining claims processing
25 and provider reimbursement, reducing the number of pending or
26 rejected claims, and helping to ensure a more transparent
SB3365 Enrolled - 27 - LRB104 18483 SSS 31925 b
1 adjudication process through the utilization of: (i) provider
2 data verification and provider screening technology; and (ii)
3 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
4 post-adjudicated predictive modeling with an integrated case
5 management system with link analysis. Such a request for
6 information shall not be considered as a request for proposal
7 or as an obligation on the part of the Illinois Department to
8 take any action or acquire any products or services.
9 The Illinois Department shall establish policies,
10 procedures, standards and criteria by rule for the
11 acquisition, repair and replacement of orthotic and prosthetic
12 devices and durable medical equipment. Such rules shall
13 provide, but not be limited to, the following services: (1)
14 immediate repair or replacement of such devices by recipients;
15 and (2) rental, lease, purchase or lease-purchase of durable
16 medical equipment in a cost-effective manner, taking into
17 consideration the recipient's medical prognosis, the extent of
18 the recipient's needs, and the requirements and costs for
19 maintaining such equipment. Subject to prior approval, such
20 rules shall enable a recipient to temporarily acquire and use
21 alternative or substitute devices or equipment pending repairs
22 or replacements of any device or equipment previously
23 authorized for such recipient by the Department.
24 Notwithstanding any provision of Section 5-5f to the contrary,
25 the Department may, by rule, exempt certain replacement
26 wheelchair parts from prior approval and, for wheelchairs,
SB3365 Enrolled - 28 - LRB104 18483 SSS 31925 b
1 wheelchair parts, wheelchair accessories, and related seating
2 and positioning items, determine the wholesale price by
3 methods other than actual acquisition costs.
4 The Department shall require, by rule, all providers of
5 durable medical equipment to be accredited by an accreditation
6 organization approved by the federal Centers for Medicare and
7 Medicaid Services and recognized by the Department in order to
8 bill the Department for providing durable medical equipment to
9 recipients. No later than 15 months after the effective date
10 of the rule adopted pursuant to this paragraph, all providers
11 must meet the accreditation requirement.
12 In order to promote environmental responsibility, meet the
13 needs of recipients and enrollees, and achieve significant
14 cost savings, the Department, or a managed care organization
15 under contract with the Department, may provide recipients or
16 managed care enrollees who have a prescription or Certificate
17 of Medical Necessity access to refurbished durable medical
18 equipment under this Section (excluding prosthetic and
19 orthotic devices as defined in the Orthotics, Prosthetics, and
20 Pedorthics Practice Act and complex rehabilitation technology
21 products and associated services) through the State's
22 assistive technology program's reutilization program, using
23 staff with the Assistive Technology Professional (ATP)
24 Certification if the refurbished durable medical equipment:
25 (i) is available; (ii) is less expensive, including shipping
26 costs, than new durable medical equipment of the same type;
SB3365 Enrolled - 29 - LRB104 18483 SSS 31925 b
1 (iii) is able to withstand at least 3 years of use; (iv) is
2 cleaned, disinfected, sterilized, and safe in accordance with
3 federal Food and Drug Administration regulations and guidance
4 governing the reprocessing of medical devices in health care
5 settings; and (v) equally meets the needs of the recipient or
6 enrollee. The reutilization program shall confirm that the
7 recipient or enrollee is not already in receipt of the same or
8 similar equipment from another service provider, and that the
9 refurbished durable medical equipment equally meets the needs
10 of the recipient or enrollee. Nothing in this paragraph shall
11 be construed to limit recipient or enrollee choice to obtain
12 new durable medical equipment or place any additional prior
13 authorization conditions on enrollees of managed care
14 organizations.
15 The Department shall execute, relative to the nursing home
16 prescreening project, written inter-agency agreements with the
17 Department of Human Services and the Department on Aging, to
18 effect the following: (i) intake procedures and common
19 eligibility criteria for those persons who are receiving
20 non-institutional services; and (ii) the establishment and
21 development of non-institutional services in areas of the
22 State where they are not currently available or are
23 undeveloped; and (iii) notwithstanding any other provision of
24 law, subject to federal approval, on and after July 1, 2012, an
25 increase in the determination of need (DON) scores from 29 to
26 37 for applicants for institutional and home and
SB3365 Enrolled - 30 - LRB104 18483 SSS 31925 b
1 community-based long term care; if and only if federal
2 approval is not granted, the Department may, in conjunction
3 with other affected agencies, implement utilization controls
4 or changes in benefit packages to effectuate a similar savings
5 amount for this population; and (iv) no later than July 1,
6 2013, minimum level of care eligibility criteria for
7 institutional and home and community-based long term care; and
8 (v) no later than October 1, 2013, establish procedures to
9 permit long term care providers access to eligibility scores
10 for individuals with an admission date who are seeking or
11 receiving services from the long term care provider. In order
12 to select the minimum level of care eligibility criteria, the
13 Governor shall establish a workgroup that includes affected
14 agency representatives and stakeholders representing the
15 institutional and home and community-based long term care
16 interests. This Section shall not restrict the Department from
17 implementing lower level of care eligibility criteria for
18 community-based services in circumstances where federal
19 approval has been granted.
20 The Illinois Department shall develop and operate, in
21 cooperation with other State Departments and agencies and in
22 compliance with applicable federal laws and regulations,
23 appropriate and effective systems of health care evaluation
24 and programs for monitoring of utilization of health care
25 services and facilities, as it affects persons eligible for
26 medical assistance under this Code.
SB3365 Enrolled - 31 - LRB104 18483 SSS 31925 b
1 The Illinois Department shall report annually to the
2 General Assembly, no later than the second Friday in April of
3 1979 and each year thereafter, in regard to:
4 (a) actual statistics and trends in utilization of
5 medical services by public aid recipients;
6 (b) actual statistics and trends in the provision of
7 the various medical services by medical vendors;
8 (c) current rate structures and proposed changes in
9 those rate structures for the various medical vendors; and
10 (d) efforts at utilization review and control by the
11 Illinois Department.
12 The period covered by each report shall be the 3 years
13 ending on the June 30 prior to the report. The report shall
14 include suggested legislation for consideration by the General
15 Assembly. The requirement for reporting to the General
16 Assembly shall be satisfied by filing copies of the report as
17 required by Section 3.1 of the General Assembly Organization
18 Act, and filing such additional copies with the State
19 Government Report Distribution Center for the General Assembly
20 as is required under paragraph (t) of Section 7 of the State
21 Library Act.
22 Rulemaking authority to implement Public Act 95-1045, if
23 any, is conditioned on the rules being adopted in accordance
24 with all provisions of the Illinois Administrative Procedure
25 Act and all rules and procedures of the Joint Committee on
26 Administrative Rules; any purported rule not so adopted, for
SB3365 Enrolled - 32 - LRB104 18483 SSS 31925 b
1 whatever reason, is unauthorized.
2 On and after July 1, 2012, the Department shall reduce any
3 rate of reimbursement for services or other payments or alter
4 any methodologies authorized by this Code to reduce any rate
5 of reimbursement for services or other payments in accordance
6 with Section 5-5e.
7 Because kidney transplantation can be an appropriate,
8 cost-effective alternative to renal dialysis when medically
9 necessary and notwithstanding the provisions of Section 1-11
10 of this Code, beginning October 1, 2014, the Department shall
11 cover kidney transplantation for noncitizens with end-stage
12 renal disease who are not eligible for comprehensive medical
13 benefits, who meet the residency requirements of Section 5-3
14 of this Code, and who would otherwise meet the financial
15 requirements of the appropriate class of eligible persons
16 under Section 5-2 of this Code. To qualify for coverage of
17 kidney transplantation, such person must be receiving
18 emergency renal dialysis services covered by the Department.
19 Providers under this Section shall be prior approved and
20 certified by the Department to perform kidney transplantation
21 and the services under this Section shall be limited to
22 services associated with kidney transplantation.
23 Notwithstanding any other provision of this Code to the
24 contrary, on or after July 1, 2015, all FDA-approved forms of
25 medication assisted treatment prescribed for the treatment of
26 alcohol dependence or treatment of opioid dependence shall be
SB3365 Enrolled - 33 - LRB104 18483 SSS 31925 b
1 covered under both fee-for-service and managed care medical
2 assistance programs for persons who are otherwise eligible for
3 medical assistance under this Article and shall not be subject
4 to any (1) utilization control, other than those established
5 under the American Society of Addiction Medicine patient
6 placement criteria, (2) prior authorization mandate, (3)
7 lifetime restriction limit mandate, or (4) limitations on
8 dosage.
9 On or after July 1, 2015, opioid antagonists prescribed
10 for the treatment of an opioid overdose, including the
11 medication product, administration devices, and any pharmacy
12 fees or hospital fees related to the dispensing, distribution,
13 and administration of the opioid antagonist, shall be covered
14 under the medical assistance program for persons who are
15 otherwise eligible for medical assistance under this Article.
16 As used in this Section, "opioid antagonist" means a drug that
17 binds to opioid receptors and blocks or inhibits the effect of
18 opioids acting on those receptors, including, but not limited
19 to, naloxone hydrochloride or any other similarly acting drug
20 approved by the U.S. Food and Drug Administration. The
21 Department shall not impose a copayment on the coverage
22 provided for naloxone hydrochloride under the medical
23 assistance program.
24 Upon federal approval, the Department shall provide
25 coverage and reimbursement for all drugs that are approved for
26 marketing by the federal Food and Drug Administration and that
SB3365 Enrolled - 34 - LRB104 18483 SSS 31925 b
1 are recommended by the federal Public Health Service or the
2 United States Centers for Disease Control and Prevention for
3 pre-exposure prophylaxis and related pre-exposure prophylaxis
4 services, including, but not limited to, HIV and sexually
5 transmitted infection screening, treatment for sexually
6 transmitted infections, medical monitoring, assorted labs, and
7 counseling to reduce the likelihood of HIV infection among
8 individuals who are not infected with HIV but who are at high
9 risk of HIV infection.
10 A federally qualified health center, as defined in Section
11 1905(l)(2)(B) of the federal Social Security Act, shall be
12 reimbursed by the Department in accordance with the federally
13 qualified health center's encounter rate for services provided
14 to medical assistance recipients that are performed by a
15 dental hygienist, as defined under the Illinois Dental
16 Practice Act, working under the general supervision of a
17 dentist and employed by a federally qualified health center.
18 Within 90 days after October 8, 2021 (the effective date
19 of Public Act 102-665), the Department shall seek federal
20 approval of a State Plan amendment to expand coverage for
21 family planning services that includes presumptive eligibility
22 to individuals whose income is at or below 208% of the federal
23 poverty level. Coverage under this Section shall be effective
24 beginning no later than December 1, 2022.
25 Subject to approval by the federal Centers for Medicare
26 and Medicaid Services of a Title XIX State Plan amendment
SB3365 Enrolled - 35 - LRB104 18483 SSS 31925 b
1 electing the Program of All-Inclusive Care for the Elderly
2 (PACE) as a State Medicaid option, as provided for by Subtitle
3 I (commencing with Section 4801) of Title IV of the Balanced
4 Budget Act of 1997 (Public Law 105-33) and Part 460
5 (commencing with Section 460.2) of Subchapter E of Title 42 of
6 the Code of Federal Regulations, PACE program services shall
7 become a covered benefit of the medical assistance program,
8 subject to criteria established in accordance with all
9 applicable laws.
10 Notwithstanding any other provision of this Code,
11 community-based pediatric palliative care from a trained
12 interdisciplinary team shall be covered under the medical
13 assistance program as provided in Section 15 of the Pediatric
14 Palliative Care Act.
15 Notwithstanding any other provision of this Code, within
16 12 months after June 2, 2022 (the effective date of Public Act
17 102-1037) and subject to federal approval, acupuncture
18 services performed by an acupuncturist licensed under the
19 Acupuncture Practice Act who is acting within the scope of his
20 or her license shall be covered under the medical assistance
21 program. The Department shall apply for any federal waiver or
22 State Plan amendment, if required, to implement this
23 paragraph. The Department may adopt any rules, including
24 standards and criteria, necessary to implement this paragraph.
25 Notwithstanding any other provision of this Code, the
26 medical assistance program shall, subject to federal approval,
SB3365 Enrolled - 36 - LRB104 18483 SSS 31925 b
1 reimburse hospitals for costs associated with a newborn
2 screening test for the presence of metachromatic
3 leukodystrophy, as required under the Newborn Metabolic
4 Screening Act, at a rate not less than the fee charged by the
5 Department of Public Health. Notwithstanding any other
6 provision of this Code, the medical assistance program shall,
7 subject to appropriation and federal approval, also reimburse
8 hospitals for costs associated with all newborn screening
9 tests added on and after August 9, 2024 (the effective date of
10 Public Act 103-909) to the Newborn Metabolic Screening Act and
11 required to be performed under that Act at a rate not less than
12 the fee charged by the Department of Public Health. The
13 Department shall seek federal approval before the
14 implementation of the newborn screening test fees by the
15 Department of Public Health.
16 Notwithstanding any other provision of this Code,
17 beginning on January 1, 2024, subject to federal approval,
18 cognitive assessment and care planning services provided to a
19 person who experiences signs or symptoms of cognitive
20 impairment, as defined by the Diagnostic and Statistical
21 Manual of Mental Disorders, Fifth Edition, shall be covered
22 under the medical assistance program for persons who are
23 otherwise eligible for medical assistance under this Article.
24 Notwithstanding any other provision of this Code,
25 medically necessary reconstructive services that are intended
26 to restore physical appearance shall be covered under the
SB3365 Enrolled - 37 - LRB104 18483 SSS 31925 b
1 medical assistance program for persons who are otherwise
2 eligible for medical assistance under this Article. As used in
3 this paragraph, "reconstructive services" means treatments
4 performed on structures of the body damaged by trauma to
5 restore physical appearance.
6 Subject to federal approval, for dates of services on and
7 after January 1, 2026, over-the-counter choline dietary
8 supplements for pregnant persons shall be covered under the
9 medical assistance program.
10 (Source: P.A. 103-102, Article 15, Section 15-5, eff. 1-1-24;
11 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff.
12 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593,
13 Article 5, Section 5-5, eff. 6-7-24; 103-593, Article 90,
14 Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-808, eff.
15 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; 104-9,
16 eff. 6-16-25; 104-417, eff. 8-15-25.)
17 ARTICLE 6.
18 Section 6-5. The Illinois Public Aid Code is amended by
19 adding Article V-J as follows:
20 (305 ILCS 5/Art. V-J heading new)
21 ARTICLE V-J. DISTRESSED HOSPITAL LOAN PROGRAM
22 (305 ILCS 5/5J-1 new)
SB3365 Enrolled - 38 - LRB104 18483 SSS 31925 b
1 Sec. 5J-1. References to Article. This Article may be
2 referred to as the Distressed Hospital Loan Program Law.
3 (305 ILCS 5/5J-5 new)
4 Sec. 5J-5. Distressed Hospital Loan Program. The
5 Distressed Hospital Loan Program is created. The purpose of
6 the Program is to provide, subject to appropriation and the
7 availability of funds, interest-free cash flow loans to
8 public, not-for-profit, and for-profit hospitals in
9 significant financial distress to prevent the closure of or to
10 facilitate the reopening of those hospitals.
11 (305 ILCS 5/5J-10 new)
12 Sec. 5J-10. Definitions. As used in this Article:
13 "Closed hospital" means a hospital that closed after
14 January 1, 2019.
15 "Department" means the Department of Healthcare and Family
16 Services.
17 "Program" means the Distressed Hospital Loan Program.
18 "Public hospital" means a hospital that is licensed by the
19 Hospital Licensing Act and is either owned or operated by a
20 governmental body in Illinois, excluding a State agency, a
21 State university, or a county with a population of 3,000,000
22 or more.
23 (305 ILCS 5/5J-15 new)
SB3365 Enrolled - 39 - LRB104 18483 SSS 31925 b
1 Sec. 5J-15. Administration. The Department shall
2 administer the Distressed Hospital Loan Program in
3 coordination with the Department of Public Health and the
4 Governor's Office of Management and Budget. The Department
5 shall adopt rules to implement this Program.
6 (305 ILCS 5/5J-18 new)
7 Sec. 5J-18. Application requirements. A hospital applying
8 for aid under this Program shall provide the Department with
9 financial information, in a format determined by the
10 Department, demonstrating the hospital's need for bridge
11 financing due to financial hardship.
12 (1) Before receiving bridge financing under this
13 Program, an eligible hospital shall submit a plan to the
14 Department, with projections detailing the uses of the
15 proposed loan and a structured plan proposed by the
16 hospital's governing body to regain financial viability
17 and continue operations.
18 (2) Before issuing a loan under this Program, the
19 Department shall review the plan submitted by an eligible
20 hospital and make a determination both that the plan is
21 viable and that there is a reasonable likelihood that the
22 hospital will be able to regain financial viability,
23 continue to operate as a hospital, and be able to repay the
24 loan. The Department shall not issue a loan award if the
25 Department is unable to make these determinations.
SB3365 Enrolled - 40 - LRB104 18483 SSS 31925 b
1 (3) All funds loaned in accordance with this Article
2 shall be used as described in the application approved by
3 the Department, which shall be incorporated into any
4 resulting loan agreement. Any misused funds shall be
5 recouped by the Department subject to the recoupment
6 methods under Section 5J-25. In addition to any other
7 remedies provided for by law and without sending a notice
8 of liability, the Department may withhold, as payment of
9 any amounts due and owing as repayment of loans issued in
10 accordance with this Article, reimbursements or other
11 amounts otherwise payable by the Department to the loan
12 recipient, including, but not limited to, amounts
13 otherwise payable from a managed care organization
14 performing duties under contract with the Department.
15 (305 ILCS 5/5J-20 new)
16 Sec. 5J-20. Application evaluation.
17 (a) In collaboration with the Governor's Office of
18 Management and Budget and the Department of Public Health, the
19 Department shall develop a methodology to evaluate a
20 hospital's application for a loan through the Program.
21 (b) The methodology shall consider factors including, but
22 not limited to, whether the hospital is in financial distress
23 as solely determined by the State; whether the hospital is
24 small, rural, a safety-net hospital, a critical access
25 hospital, a trauma center, an urban hospital providing access
SB3365 Enrolled - 41 - LRB104 18483 SSS 31925 b
1 for an underserved area, a hospital that serves a
2 disproportionate share of Medicaid patients, or serving a
3 rural catchment area; and whether closure of the hospital or
4 service line reduction as a result of the financial distress
5 would significantly impact access to services in the
6 hospital's health service area.
7 (c) The methodology for determining financial distress may
8 consider such factors as the hospital's prior and projected
9 performance on financial metrics, including the amount of cash
10 on hand, and whether the hospital has experienced, or is
11 projected to experience, negative operating margins.
12 (d) Subject to appropriation and the availability of
13 funds, any loan to a hospital with an approved loan
14 application shall be issued as soon as reasonably practicable
15 following approval of an application. Approved applications
16 shall receive funding on a first-come, first-served basis
17 until funding appropriated by the General Assembly for this
18 purpose has been expended. The Department maintains discretion
19 to determine the amount of a loan approved for a hospital and
20 may approve less than the amount requested by a hospital. The
21 Department may consider the amount of appropriations available
22 to this Program in the exercise of its discretion.
23 (e) Hospitals ineligible for State assistance under the
24 Program include:
25 (1) Hospitals that belong to integrated health care
26 systems with more than 3 separately licensed hospital
SB3365 Enrolled - 42 - LRB104 18483 SSS 31925 b
1 facilities.
2 (2) A hospital that maintains unpaid hospital
3 assessment liability owed to the State and either does not
4 have a negotiated tax repayment agreement with the State
5 or is delinquent under an existing negotiated assessment
6 repayment agreement.
7 (3) A hospital that is not current on a repayment
8 schedule for a prior advance issued in accordance with 89
9 Ill. Adm. Code 140.71.
10 (4) A hospital that has not provided required
11 reporting on its finances as mandated by State law or
12 administrative rule.
13 (5) A hospital that is subject to a stop payment
14 order, as defined by the Grant Accountability and
15 Transparency Act, with the State for any reason.
16 (6) A hospital that has been under investigation or
17 been issued an immediate jeopardy by the Centers for
18 Medicare and Medicaid Services in the prior 12 months from
19 the time of loan application.
20 (f) The Department shall give preference to not-for-profit
21 and public hospitals. Hospitals owned and operated by a
22 for-profit entity shall be subject to a maximum funding limit,
23 expedited repayment time frames, and additional financial and
24 operational transparency requirements as defined in rule.
25 (g) The Department shall determine the application
26 process, underwriting review, and methodology for approval and
SB3365 Enrolled - 43 - LRB104 18483 SSS 31925 b
1 distribution of the loans under the Program.
2 (h) The Department shall have the authority to determine
3 service provision requirements in approving, and for the
4 duration of, loans to eligible hospitals. In making its
5 determination, the Department shall consider the impact of any
6 changes to the hospital's service delivery or access to
7 necessary medical care, particularly for beneficiaries of the
8 State's medical assistance Program.
9 (i) The application process shall allow for at least 30
10 days for the Department to issue an initial response to any
11 loan application.
12 (305 ILCS 5/5J-25 new)
13 Sec. 5J-25. Repayment agreement.
14 (a) A hospital shall be required to enter into a repayment
15 agreement with the Department to execute the approved loan.
16 Terms must include, but are not limited to, monthly repayments
17 of the loan beginning no later than 18 months after receipt of
18 the loan and discharge of the loan within 36 months of the date
19 of the loan.
20 (b) Notwithstanding any other law and to the extent
21 permissible under federal rules, security for the cash flow
22 loans in this Article shall, at a minimum, include
23 reimbursements due to the hospital from the Department,
24 including, but not limited to, any reimbursements under this
25 Code. The repayment agreement may provide for additional
SB3365 Enrolled - 44 - LRB104 18483 SSS 31925 b
1 security for any cash flow loans under this Article.
2 (c) If the hospital provider fails to comply with the
3 repayment terms of the agreement, the remaining balance of the
4 loan shall be immediately recouped from reimbursements or
5 other amounts otherwise payable by the Department to the loan
6 recipient, including, but not limited to, amounts otherwise
7 payable from a managed care organization performing duties
8 under contract with the Department. The Department may also
9 recoup amounts otherwise payable by any State agency to the
10 provider, including, but not limited to, State grants and
11 grant appropriations, and apply such amounts as repayment of
12 the unpaid advance. If such reimbursements or other amounts
13 otherwise payable to the loan recipient are insufficient for
14 complete recovery, the remaining balance shall become
15 immediately due and payable by check to the Department of
16 Healthcare and Family Services. Failure by the provider to
17 remit such check shall result in the Department pursuing other
18 collection methods.
19 (d) Any unpaid loan under this Article shall become a lien
20 upon the assets of the hospital that received the loan. If any
21 hospital provider, outside the usual course of its business,
22 sells or transfers the major part of any one or more of (A) the
23 real property and improvements, (B) the machinery and
24 equipment, or (C) the furniture or fixtures, of any hospital
25 that is subject to the provisions of this Article, the seller
26 or transferor shall pay the Department the amount of any loan,
SB3365 Enrolled - 45 - LRB104 18483 SSS 31925 b
1 penalty, and interest (if any) due from it under this Article
2 up to the date of the sale or transfer. The Department may, in
3 its discretion, foreclose on such a lien, but shall do so in a
4 manner that is consistent with Section 5e of the Retailers'
5 Occupation Tax Act. If the seller or transferor fails to pay
6 any loan, penalty, and interest (if any) due, the purchaser or
7 transferee of such asset shall be liable for the amount of the
8 loan, penalties, and interest (if any) up to the amount of the
9 reasonable value of the property acquired by the purchaser or
10 transferee. The purchaser or transferee shall continue to be
11 liable until the purchaser or transferee pays the full amount
12 of the loan, penalties, and interest (if any) up to the amount
13 of the reasonable value of the property acquired by the
14 purchaser or transferee or until the purchaser or transferee
15 receives from the Department a certificate showing that such
16 loan, penalty, and interest have been paid or a certificate
17 from the Department showing that no loan, penalty, or interest
18 is due from the seller or transferor under this Article.
19 (e) If a hospital provider fails to pay any monthly
20 installment repayments, there shall, unless waived by the
21 Department for reasonable cause, be added to the loan
22 repayment obligation a penalty equal to the lesser of (i) 5% of
23 the amount of the installment not paid on or before the due
24 date plus 5% of the portion thereof remaining unpaid on the
25 last day of each 30-day period thereafter or (ii) 100% of the
26 installment amount not paid on or before the due date.
SB3365 Enrolled - 46 - LRB104 18483 SSS 31925 b
1 (305 ILCS 5/5J-30 new)
2 Sec. 5J-30. Distressed Hospital Loan Program Fund.
3 (a) The Distressed Hospital Loan Program Fund is created
4 as a special fund in the State treasury.
5 (b) Subject to appropriation, the Department may make
6 secured and unsecured loans from amounts in the Distressed
7 Hospital Loan Program Fund to a hospital, or a governmental
8 entity representing a closed hospital, for purposes of
9 preventing the hospital's closure in accordance with the
10 provisions of this Article.
11 (c) On January 1, 2027, or as soon thereafter as
12 practical, the State Comptroller shall direct and the State
13 Treasurer shall transfer, at the direction of the Director of
14 the Department, an amount not to exceed $85,000,000 from the
15 Healthcare Provider Relief Fund to the Distressed Hospital
16 Loan Program Fund.
17 (d) All moneys accruing to the Department under this
18 Article from any source, including, but not limited to, all
19 amounts repaid under the terms of any loan agreements, shall
20 be deposited into the Fund.
21 (e) On June 30, 2033, or as soon thereafter as practical,
22 the State Comptroller shall direct and the State Treasurer
23 shall transfer the remaining balance in the Distressed
24 Hospital Loan Program Fund to the Healthcare Provider Relief
25 Fund. Upon completion of the transfers, the Distressed
SB3365 Enrolled - 47 - LRB104 18483 SSS 31925 b
1 Hospital Loan Program Fund is dissolved and any outstanding
2 obligations or liabilities of the Fund pass to the Healthcare
3 Provider Relief Fund. The Department shall deposit all
4 subsequent loan repayments or medical assistance program or
5 other reimbursements withheld for due cause in accordance with
6 this Article into the Healthcare Provider Relief Fund.
7 (f) The Department may require any hospital receiving a
8 loan under this Article to provide the Department with an
9 independent financial audit of the hospital's operations for
10 any fiscal year in which a loan is outstanding.
11 (305 ILCS 5/5J-35 new)
12 Sec. 5J-35. Implementation. The Program described in this
13 Article shall be operative on and after January 1, 2027 and
14 shall be implemented upon administrative rules being in
15 effect.
16 (305 ILCS 5/5J-40 new)
17 Sec. 5J-40. Repealer. This Article is repealed on June 30,
18 2033.
19 Section 6-70. The State Finance Act is amended by adding
20 Section 5.1038 as follows:
21 (30 ILCS 105/5.1038 new)
22 Sec. 5.1038. The Distressed Hospital Loan Program Fund.
SB3365 Enrolled - 48 - LRB104 18483 SSS 31925 b
1 This Section is repealed June 30, 2033.
2 Section 6-72. The Illinois Administrative Procedure Act is
3 amended by adding Section 5-45.71 as follows:
4 (5 ILCS 100/5-45.71 new)
5 Sec. 5-45.71. Emergency rulemaking; Health Facilities and
6 Services Review Board. To provide for the expeditious and
7 timely implementation of the changes made by this amendatory
8 Act of the 104th General Assembly to Section 13 of the Illinois
9 Health Facilities Planning Act, emergency rules may be adopted
10 in accordance with Section 5-45 by the Health Facilities and
11 Services Review Board. The adoption of emergency rules
12 authorized by Section 5-45 and this Section is deemed to be
13 necessary for the public interest, safety, and welfare.
14 This Section is repealed one year after the effective date
15 of this amendatory Act of the 104th General Assembly.
16 Section 6-73. The Freedom of Information Act is amended by
17 changing Section 7.5 as follows:
18 (5 ILCS 140/7.5)
19 (Text of Section before amendment by P.A. 104-441 and
20 104-457)
21 Sec. 7.5. Statutory exemptions. To the extent provided for
22 by the statutes referenced below, the following shall be
SB3365 Enrolled - 49 - LRB104 18483 SSS 31925 b
1 exempt from inspection and copying:
2 (a) All information determined to be confidential
3 under Section 4002 of the Technology Advancement and
4 Development Act.
5 (b) Library circulation and order records identifying
6 library users with specific materials under the Library
7 Records Confidentiality Act.
8 (c) Applications, related documents, and medical
9 records received by the Experimental Organ Transplantation
10 Procedures Board and any and all documents or other
11 records prepared by the Experimental Organ Transplantation
12 Procedures Board or its staff relating to applications it
13 has received.
14 (d) Information and records held by the Department of
15 Public Health and its authorized representatives relating
16 to known or suspected cases of sexually transmitted
17 infection or any information the disclosure of which is
18 restricted under the Illinois Sexually Transmitted
19 Infection Control Act.
20 (e) Information the disclosure of which is exempted
21 under Section 30 of the Radon Industry Licensing Act.
22 (f) Firm performance evaluations under Section 55 of
23 the Architectural, Engineering, and Land Surveying
24 Qualifications Based Selection Act.
25 (g) Information the disclosure of which is restricted
26 and exempted under Section 50 of the Illinois Prepaid
SB3365 Enrolled - 50 - LRB104 18483 SSS 31925 b
1 Tuition Act.
2 (h) Information the disclosure of which is exempted
3 under the State Officials and Employees Ethics Act, and
4 records of any lawfully created State or local inspector
5 general's office that would be exempt if created or
6 obtained by an Executive Inspector General's office under
7 that Act.
8 (i) Information contained in a local emergency energy
9 plan submitted to a municipality in accordance with a
10 local emergency energy plan ordinance that is adopted
11 under Section 11-21.5-5 of the Illinois Municipal Code.
12 (j) Information and data concerning the distribution
13 of surcharge moneys collected and remitted by carriers
14 under the Emergency Telephone System Act.
15 (k) Law enforcement officer identification information
16 or driver identification information compiled by a law
17 enforcement agency or the Department of Transportation
18 under Section 11-212 of the Illinois Vehicle Code.
19 (l) Records and information provided to a residential
20 health care facility resident sexual assault and death
21 review team or the Executive Council under the Abuse
22 Prevention Review Team Act.
23 (m) Information provided to the predatory lending
24 database created pursuant to Article 3 of the Residential
25 Real Property Disclosure Act, except to the extent
26 authorized under that Article.
SB3365 Enrolled - 51 - LRB104 18483 SSS 31925 b
1 (n) Defense budgets and petitions for certification of
2 compensation and expenses for court appointed trial
3 counsel as provided under Sections 10 and 15 of the
4 Capital Crimes Litigation Act (repealed). This subsection
5 (n) shall apply until the conclusion of the trial of the
6 case, even if the prosecution chooses not to pursue the
7 death penalty prior to trial or sentencing.
8 (o) Information that is prohibited from being
9 disclosed under Section 4 of the Illinois Health and
10 Hazardous Substances Registry Act.
11 (p) Security portions of system safety program plans,
12 investigation reports, surveys, schedules, lists, data, or
13 information compiled, collected, or prepared by or for the
14 Department of Transportation under Sections 2705-300 and
15 2705-616 of the Department of Transportation Law of the
16 Civil Administrative Code of Illinois, the Regional
17 Transportation Authority under Section 2.11 of the
18 Regional Transportation Authority Act, or the St. Clair
19 County Transit District under the Bi-State Transit Safety
20 Act (repealed).
21 (q) Information prohibited from being disclosed by the
22 Personnel Record Review Act.
23 (r) Information prohibited from being disclosed by the
24 Illinois School Student Records Act.
25 (s) Information the disclosure of which is restricted
26 under Section 5-108 of the Public Utilities Act.
SB3365 Enrolled - 52 - LRB104 18483 SSS 31925 b
1 (t) (Blank).
2 (u) Records and information provided to an independent
3 team of experts under the Developmental Disability and
4 Mental Health Safety Act (also known as Brian's Law).
5 (v) Names and information of people who have applied
6 for or received Firearm Owner's Identification Cards under
7 the Firearm Owners Identification Card Act or applied for
8 or received a concealed carry license under the Firearm
9 Concealed Carry Act, unless otherwise authorized by the
10 Firearm Concealed Carry Act; and databases under the
11 Firearm Concealed Carry Act, records of the Concealed
12 Carry Licensing Review Board under the Firearm Concealed
13 Carry Act, and law enforcement agency objections under the
14 Firearm Concealed Carry Act.
15 (v-5) Records of the Firearm Owner's Identification
16 Card Review Board that are exempted from disclosure under
17 Section 10 of the Firearm Owners Identification Card Act.
18 (w) Personally identifiable information which is
19 exempted from disclosure under subsection (g) of Section
20 19.1 of the Toll Highway Act.
21 (x) Information which is exempted from disclosure
22 under Section 5-1014.3 of the Counties Code or Section
23 8-11-21 of the Illinois Municipal Code.
24 (y) Confidential information under the Adult
25 Protective Services Act and its predecessor enabling
26 statute, the Elder Abuse and Neglect Act, including
SB3365 Enrolled - 53 - LRB104 18483 SSS 31925 b
1 information about the identity and administrative finding
2 against any caregiver of a verified and substantiated
3 decision of abuse, neglect, or financial exploitation of
4 an eligible adult maintained in the Registry established
5 under Section 7.5 of the Adult Protective Services Act.
6 (z) Records and information provided to a fatality
7 review team or the Illinois Fatality Review Team Advisory
8 Council under Section 15 of the Adult Protective Services
9 Act.
10 (aa) Information which is exempted from disclosure
11 under Section 2.37 of the Wildlife Code.
12 (bb) Information which is or was prohibited from
13 disclosure by the Juvenile Court Act of 1987.
14 (cc) Recordings made under the Law Enforcement
15 Officer-Worn Body Camera Act, except to the extent
16 authorized under that Act.
17 (dd) Information that is prohibited from being
18 disclosed under Section 45 of the Condominium and Common
19 Interest Community Ombudsperson Act.
20 (ee) Information that is exempted from disclosure
21 under Section 30.1 of the Pharmacy Practice Act.
22 (ff) Information that is exempted from disclosure
23 under the Revised Uniform Unclaimed Property Act.
24 (gg) Information that is prohibited from being
25 disclosed under Section 7-603.5 of the Illinois Vehicle
26 Code.
SB3365 Enrolled - 54 - LRB104 18483 SSS 31925 b
1 (hh) Records that are exempt from disclosure under
2 Section 1A-16.7 of the Election Code.
3 (ii) Information which is exempted from disclosure
4 under Section 2505-800 of the Department of Revenue Law of
5 the Civil Administrative Code of Illinois.
6 (jj) Information and reports that are required to be
7 submitted to the Department of Labor by registering day
8 and temporary labor service agencies but are exempt from
9 disclosure under subsection (a-1) of Section 45 of the Day
10 and Temporary Labor Services Act.
11 (kk) Information prohibited from disclosure under the
12 Seizure and Forfeiture Reporting Act.
13 (ll) Information the disclosure of which is restricted
14 and exempted under Section 5-30.8 of the Illinois Public
15 Aid Code.
16 (mm) Records that are exempt from disclosure under
17 Section 4.2 of the Crime Victims Compensation Act.
18 (nn) Information that is exempt from disclosure under
19 Section 70 of the Higher Education Student Assistance Act.
20 (oo) Communications, notes, records, and reports
21 arising out of a peer support counseling session
22 prohibited from disclosure under the First Responders
23 Suicide Prevention Act.
24 (pp) Names and all identifying information relating to
25 an employee of an emergency services provider or law
26 enforcement agency under the First Responders Suicide
SB3365 Enrolled - 55 - LRB104 18483 SSS 31925 b
1 Prevention Act.
2 (qq) Information and records held by the Department of
3 Public Health and its authorized representatives collected
4 under the Reproductive Health Act.
5 (rr) Information that is exempt from disclosure under
6 the Cannabis Regulation and Tax Act.
7 (ss) Data reported by an employer to the Department of
8 Human Rights pursuant to Section 2-108 of the Illinois
9 Human Rights Act.
10 (tt) Recordings made under the Children's Advocacy
11 Center Act, except to the extent authorized under that
12 Act.
13 (uu) Information that is exempt from disclosure under
14 Section 50 of the Sexual Assault Evidence Submission Act.
15 (vv) Information that is exempt from disclosure under
16 subsections (f) and (j) of Section 5-36 of the Illinois
17 Public Aid Code.
18 (ww) Information that is exempt from disclosure under
19 Section 16.8 of the State Treasurer Act.
20 (xx) Information that is exempt from disclosure or
21 information that shall not be made public under the
22 Illinois Insurance Code.
23 (yy) Information prohibited from being disclosed under
24 the Illinois Educational Labor Relations Act.
25 (zz) Information prohibited from being disclosed under
26 the Illinois Public Labor Relations Act.
SB3365 Enrolled - 56 - LRB104 18483 SSS 31925 b
1 (aaa) Information prohibited from being disclosed
2 under Section 1-167 of the Illinois Pension Code.
3 (bbb) Information that is prohibited from disclosure
4 by the Illinois Police Training Act and the Illinois State
5 Police Act.
6 (ccc) Records exempt from disclosure under Section
7 2605-304 of the Illinois State Police Law of the Civil
8 Administrative Code of Illinois.
9 (ddd) Information prohibited from being disclosed
10 under Section 35 of the Address Confidentiality for
11 Victims of Domestic Violence, Sexual Assault, Human
12 Trafficking, or Stalking Act.
13 (eee) Information prohibited from being disclosed
14 under subsection (b) of Section 75 of the Domestic
15 Violence Fatality Review Act.
16 (fff) Images from cameras under the Expressway Camera
17 Act and all automated license plate reader (ALPR)
18 information used and collected by the Illinois State
19 Police. "ALPR information" means information gathered by
20 an ALPR or created from the analysis of data generated by
21 an ALPR. This subsection (fff) is inoperative on and after
22 July 1, 2028.
23 (ggg) Information prohibited from disclosure under
24 paragraph (3) of subsection (a) of Section 14 of the Nurse
25 Agency Licensing Act.
26 (hhh) Information submitted to the Illinois State
SB3365 Enrolled - 57 - LRB104 18483 SSS 31925 b
1 Police in an affidavit or application for an assault
2 weapon endorsement, assault weapon attachment endorsement,
3 .50 caliber rifle endorsement, or .50 caliber cartridge
4 endorsement under the Firearm Owners Identification Card
5 Act.
6 (iii) Data exempt from disclosure under Section 50 of
7 the School Safety Drill Act.
8 (jjj) Information exempt from disclosure under Section
9 30 of the Insurance Data Security Law.
10 (kkk) Confidential business information prohibited
11 from disclosure under Section 45 of the Paint Stewardship
12 Act.
13 (lll) Data exempt from disclosure under Section
14 2-3.196 of the School Code.
15 (mmm) Information prohibited from being disclosed
16 under subsection (e) of Section 1-129 of the Illinois
17 Power Agency Act.
18 (nnn) Materials received by the Department of Commerce
19 and Economic Opportunity that are confidential under the
20 Music and Musicians Tax Credit and Jobs Act.
21 (ooo) Data or information provided pursuant to Section
22 20 of the Statewide Recycling Needs and Assessment Act.
23 (ppp) Information that is exempt from disclosure under
24 Section 28-11 of the Lawful Health Care Activity Act.
25 (qqq) Information that is exempt from disclosure under
26 Section 7-101 of the Illinois Human Rights Act.
SB3365 Enrolled - 58 - LRB104 18483 SSS 31925 b
1 (rrr) Information prohibited from being disclosed
2 under Section 4-2 of the Uniform Money Transmission
3 Modernization Act.
4 (sss) Information exempt from disclosure under Section
5 40 of the Student-Athlete Endorsement Rights Act.
6 (ttt) Audio recordings made under Section 30 of the
7 Illinois State Police Act, except to the extent authorized
8 under that Section.
9 (uuu) Information prohibited from being disclosed
10 under Section 30-5 of the Digital Assets Regulation Act.
11 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
12 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
13 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
14 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
15 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
16 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
17 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
18 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; revised
19 9-10-25.)
20 (Text of Section after amendment by P.A. 104-457 but
21 before 104-441)
22 Sec. 7.5. Statutory exemptions. To the extent provided for
23 by the statutes referenced below, the following shall be
24 exempt from inspection and copying:
25 (a) All information determined to be confidential
SB3365 Enrolled - 59 - LRB104 18483 SSS 31925 b
1 under Section 4002 of the Technology Advancement and
2 Development Act.
3 (b) Library circulation and order records identifying
4 library users with specific materials under the Library
5 Records Confidentiality Act.
6 (c) Applications, related documents, and medical
7 records received by the Experimental Organ Transplantation
8 Procedures Board and any and all documents or other
9 records prepared by the Experimental Organ Transplantation
10 Procedures Board or its staff relating to applications it
11 has received.
12 (d) Information and records held by the Department of
13 Public Health and its authorized representatives relating
14 to known or suspected cases of sexually transmitted
15 infection or any information the disclosure of which is
16 restricted under the Illinois Sexually Transmitted
17 Infection Control Act.
18 (e) Information the disclosure of which is exempted
19 under Section 30 of the Radon Industry Licensing Act.
20 (f) Firm performance evaluations under Section 55 of
21 the Architectural, Engineering, and Land Surveying
22 Qualifications Based Selection Act.
23 (g) Information the disclosure of which is restricted
24 and exempted under Section 50 of the Illinois Prepaid
25 Tuition Act.
26 (h) Information the disclosure of which is exempted
SB3365 Enrolled - 60 - LRB104 18483 SSS 31925 b
1 under the State Officials and Employees Ethics Act, and
2 records of any lawfully created State or local inspector
3 general's office that would be exempt if created or
4 obtained by an Executive Inspector General's office under
5 that Act.
6 (i) Information contained in a local emergency energy
7 plan submitted to a municipality in accordance with a
8 local emergency energy plan ordinance that is adopted
9 under Section 11-21.5-5 of the Illinois Municipal Code.
10 (j) Information and data concerning the distribution
11 of surcharge moneys collected and remitted by carriers
12 under the Emergency Telephone System Act.
13 (k) Law enforcement officer identification information
14 or driver identification information compiled by a law
15 enforcement agency or the Department of Transportation
16 under Section 11-212 of the Illinois Vehicle Code.
17 (l) Records and information provided to a residential
18 health care facility resident sexual assault and death
19 review team or the Executive Council under the Abuse
20 Prevention Review Team Act.
21 (m) Information provided to the predatory lending
22 database created pursuant to Article 3 of the Residential
23 Real Property Disclosure Act, except to the extent
24 authorized under that Article.
25 (n) Defense budgets and petitions for certification of
26 compensation and expenses for court appointed trial
SB3365 Enrolled - 61 - LRB104 18483 SSS 31925 b
1 counsel as provided under Sections 10 and 15 of the
2 Capital Crimes Litigation Act (repealed). This subsection
3 (n) shall apply until the conclusion of the trial of the
4 case, even if the prosecution chooses not to pursue the
5 death penalty prior to trial or sentencing.
6 (o) Information that is prohibited from being
7 disclosed under Section 4 of the Illinois Health and
8 Hazardous Substances Registry Act.
9 (p) Security portions of system safety program plans,
10 investigation reports, surveys, schedules, lists, data, or
11 information compiled, collected, or prepared by or for the
12 Department of Transportation under Sections 2705-300 and
13 2705-616 of the Department of Transportation Law of the
14 Civil Administrative Code of Illinois, the Northern
15 Illinois Transit Authority under Section 2.11 of the
16 Northern Illinois Transit Authority Act, or the St. Clair
17 County Transit District under the Bi-State Transit Safety
18 Act (repealed).
19 (q) Information prohibited from being disclosed by the
20 Personnel Record Review Act.
21 (r) Information prohibited from being disclosed by the
22 Illinois School Student Records Act.
23 (s) Information the disclosure of which is restricted
24 under Section 5-108 of the Public Utilities Act.
25 (t) (Blank).
26 (u) Records and information provided to an independent
SB3365 Enrolled - 62 - LRB104 18483 SSS 31925 b
1 team of experts under the Developmental Disability and
2 Mental Health Safety Act (also known as Brian's Law).
3 (v) Names and information of people who have applied
4 for or received Firearm Owner's Identification Cards under
5 the Firearm Owners Identification Card Act or applied for
6 or received a concealed carry license under the Firearm
7 Concealed Carry Act, unless otherwise authorized by the
8 Firearm Concealed Carry Act; and databases under the
9 Firearm Concealed Carry Act, records of the Concealed
10 Carry Licensing Review Board under the Firearm Concealed
11 Carry Act, and law enforcement agency objections under the
12 Firearm Concealed Carry Act.
13 (v-5) Records of the Firearm Owner's Identification
14 Card Review Board that are exempted from disclosure under
15 Section 10 of the Firearm Owners Identification Card Act.
16 (w) Personally identifiable information which is
17 exempted from disclosure under subsection (g) of Section
18 19.1 of the Toll Highway Act.
19 (x) Information which is exempted from disclosure
20 under Section 5-1014.3 of the Counties Code or Section
21 8-11-21 of the Illinois Municipal Code.
22 (y) Confidential information under the Adult
23 Protective Services Act and its predecessor enabling
24 statute, the Elder Abuse and Neglect Act, including
25 information about the identity and administrative finding
26 against any caregiver of a verified and substantiated
SB3365 Enrolled - 63 - LRB104 18483 SSS 31925 b
1 decision of abuse, neglect, or financial exploitation of
2 an eligible adult maintained in the Registry established
3 under Section 7.5 of the Adult Protective Services Act.
4 (z) Records and information provided to a fatality
5 review team or the Illinois Fatality Review Team Advisory
6 Council under Section 15 of the Adult Protective Services
7 Act.
8 (aa) Information which is exempted from disclosure
9 under Section 2.37 of the Wildlife Code.
10 (bb) Information which is or was prohibited from
11 disclosure by the Juvenile Court Act of 1987.
12 (cc) Recordings made under the Law Enforcement
13 Officer-Worn Body Camera Act, except to the extent
14 authorized under that Act.
15 (dd) Information that is prohibited from being
16 disclosed under Section 45 of the Condominium and Common
17 Interest Community Ombudsperson Act.
18 (ee) Information that is exempted from disclosure
19 under Section 30.1 of the Pharmacy Practice Act.
20 (ff) Information that is exempted from disclosure
21 under the Revised Uniform Unclaimed Property Act.
22 (gg) Information that is prohibited from being
23 disclosed under Section 7-603.5 of the Illinois Vehicle
24 Code.
25 (hh) Records that are exempt from disclosure under
26 Section 1A-16.7 of the Election Code.
SB3365 Enrolled - 64 - LRB104 18483 SSS 31925 b
1 (ii) Information which is exempted from disclosure
2 under Section 2505-800 of the Department of Revenue Law of
3 the Civil Administrative Code of Illinois.
4 (jj) Information and reports that are required to be
5 submitted to the Department of Labor by registering day
6 and temporary labor service agencies but are exempt from
7 disclosure under subsection (a-1) of Section 45 of the Day
8 and Temporary Labor Services Act.
9 (kk) Information prohibited from disclosure under the
10 Seizure and Forfeiture Reporting Act.
11 (ll) Information the disclosure of which is restricted
12 and exempted under Section 5-30.8 of the Illinois Public
13 Aid Code.
14 (mm) Records that are exempt from disclosure under
15 Section 4.2 of the Crime Victims Compensation Act.
16 (nn) Information that is exempt from disclosure under
17 Section 70 of the Higher Education Student Assistance Act.
18 (oo) Communications, notes, records, and reports
19 arising out of a peer support counseling session
20 prohibited from disclosure under the First Responders
21 Suicide Prevention Act.
22 (pp) Names and all identifying information relating to
23 an employee of an emergency services provider or law
24 enforcement agency under the First Responders Suicide
25 Prevention Act.
26 (qq) Information and records held by the Department of
SB3365 Enrolled - 65 - LRB104 18483 SSS 31925 b
1 Public Health and its authorized representatives collected
2 under the Reproductive Health Act.
3 (rr) Information that is exempt from disclosure under
4 the Cannabis Regulation and Tax Act.
5 (ss) Data reported by an employer to the Department of
6 Human Rights pursuant to Section 2-108 of the Illinois
7 Human Rights Act.
8 (tt) Recordings made under the Children's Advocacy
9 Center Act, except to the extent authorized under that
10 Act.
11 (uu) Information that is exempt from disclosure under
12 Section 50 of the Sexual Assault Evidence Submission Act.
13 (vv) Information that is exempt from disclosure under
14 subsections (f) and (j) of Section 5-36 of the Illinois
15 Public Aid Code.
16 (ww) Information that is exempt from disclosure under
17 Section 16.8 of the State Treasurer Act.
18 (xx) Information that is exempt from disclosure or
19 information that shall not be made public under the
20 Illinois Insurance Code.
21 (yy) Information prohibited from being disclosed under
22 the Illinois Educational Labor Relations Act.
23 (zz) Information prohibited from being disclosed under
24 the Illinois Public Labor Relations Act.
25 (aaa) Information prohibited from being disclosed
26 under Section 1-167 of the Illinois Pension Code.
SB3365 Enrolled - 66 - LRB104 18483 SSS 31925 b
1 (bbb) Information that is prohibited from disclosure
2 by the Illinois Police Training Act and the Illinois State
3 Police Act.
4 (ccc) Records exempt from disclosure under Section
5 2605-304 of the Illinois State Police Law of the Civil
6 Administrative Code of Illinois.
7 (ddd) Information prohibited from being disclosed
8 under Section 35 of the Address Confidentiality for
9 Victims of Domestic Violence, Sexual Assault, Human
10 Trafficking, or Stalking Act.
11 (eee) Information prohibited from being disclosed
12 under subsection (b) of Section 75 of the Domestic
13 Violence Fatality Review Act.
14 (fff) Images from cameras under the Expressway Camera
15 Act and all automated license plate reader (ALPR)
16 information used and collected by the Illinois State
17 Police. "ALPR information" means information gathered by
18 an ALPR or created from the analysis of data generated by
19 an ALPR. This subsection (fff) is inoperative on and after
20 July 1, 2028.
21 (ggg) Information prohibited from disclosure under
22 paragraph (3) of subsection (a) of Section 14 of the Nurse
23 Agency Licensing Act.
24 (hhh) Information submitted to the Illinois State
25 Police in an affidavit or application for an assault
26 weapon endorsement, assault weapon attachment endorsement,
SB3365 Enrolled - 67 - LRB104 18483 SSS 31925 b
1 .50 caliber rifle endorsement, or .50 caliber cartridge
2 endorsement under the Firearm Owners Identification Card
3 Act.
4 (iii) Data exempt from disclosure under Section 50 of
5 the School Safety Drill Act.
6 (jjj) Information exempt from disclosure under Section
7 30 of the Insurance Data Security Law.
8 (kkk) Confidential business information prohibited
9 from disclosure under Section 45 of the Paint Stewardship
10 Act.
11 (lll) Data exempt from disclosure under Section
12 2-3.196 of the School Code.
13 (mmm) Information prohibited from being disclosed
14 under subsection (e) of Section 1-129 of the Illinois
15 Power Agency Act.
16 (nnn) Materials received by the Department of Commerce
17 and Economic Opportunity that are confidential under the
18 Music and Musicians Tax Credit and Jobs Act.
19 (ooo) Data or information provided pursuant to Section
20 20 of the Statewide Recycling Needs and Assessment Act.
21 (ppp) Information that is exempt from disclosure under
22 Section 28-11 of the Lawful Health Care Activity Act.
23 (qqq) Information that is exempt from disclosure under
24 Section 7-101 of the Illinois Human Rights Act.
25 (rrr) Information prohibited from being disclosed
26 under Section 4-2 of the Uniform Money Transmission
SB3365 Enrolled - 68 - LRB104 18483 SSS 31925 b
1 Modernization Act.
2 (sss) Information exempt from disclosure under Section
3 40 of the Student-Athlete Endorsement Rights Act.
4 (ttt) Audio recordings made under Section 30 of the
5 Illinois State Police Act, except to the extent authorized
6 under that Section.
7 (uuu) Information prohibited from being disclosed
8 under Section 30-5 of the Digital Assets Regulation Act.
9 (www) Annual summary financial and utilization data
10 reports submitted to the Health Facilities and Services
11 Review Board under Section 13 of the Illinois Health
12 Facilities Planning Act.
13 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
14 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
15 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
16 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
17 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
18 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
19 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
20 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-457, eff.
21 6-1-26; revised 1-7-26.)
22 (Text of Section after amendment by P.A. 104-441)
23 Sec. 7.5. Statutory exemptions. To the extent provided for
24 by the statutes referenced below, the following shall be
25 exempt from inspection and copying:
SB3365 Enrolled - 69 - LRB104 18483 SSS 31925 b
1 (a) All information determined to be confidential
2 under Section 4002 of the Technology Advancement and
3 Development Act.
4 (b) Library circulation and order records identifying
5 library users with specific materials under the Library
6 Records Confidentiality Act.
7 (c) Applications, related documents, and medical
8 records received by the Experimental Organ Transplantation
9 Procedures Board and any and all documents or other
10 records prepared by the Experimental Organ Transplantation
11 Procedures Board or its staff relating to applications it
12 has received.
13 (d) Information and records held by the Department of
14 Public Health and its authorized representatives relating
15 to known or suspected cases of sexually transmitted
16 infection or any information the disclosure of which is
17 restricted under the Illinois Sexually Transmitted
18 Infection Control Act.
19 (e) Information the disclosure of which is exempted
20 under Section 30 of the Radon Industry Licensing Act.
21 (f) Firm performance evaluations under Section 55 of
22 the Architectural, Engineering, and Land Surveying
23 Qualifications Based Selection Act.
24 (g) Information the disclosure of which is restricted
25 and exempted under Section 50 of the Illinois Prepaid
26 Tuition Act.
SB3365 Enrolled - 70 - LRB104 18483 SSS 31925 b
1 (h) Information the disclosure of which is exempted
2 under the State Officials and Employees Ethics Act, and
3 records of any lawfully created State or local inspector
4 general's office that would be exempt if created or
5 obtained by an Executive Inspector General's office under
6 that Act.
7 (i) Information contained in a local emergency energy
8 plan submitted to a municipality in accordance with a
9 local emergency energy plan ordinance that is adopted
10 under Section 11-21.5-5 of the Illinois Municipal Code.
11 (j) Information and data concerning the distribution
12 of surcharge moneys collected and remitted by carriers
13 under the Emergency Telephone System Act.
14 (k) Law enforcement officer identification information
15 or driver identification information compiled by a law
16 enforcement agency or the Department of Transportation
17 under Section 11-212 of the Illinois Vehicle Code.
18 (l) Records and information provided to a residential
19 health care facility resident sexual assault and death
20 review team or the Executive Council under the Abuse
21 Prevention Review Team Act.
22 (m) Information provided to the predatory lending
23 database created pursuant to Article 3 of the Residential
24 Real Property Disclosure Act, except to the extent
25 authorized under that Article.
26 (n) Defense budgets and petitions for certification of
SB3365 Enrolled - 71 - LRB104 18483 SSS 31925 b
1 compensation and expenses for court appointed trial
2 counsel as provided under Sections 10 and 15 of the
3 Capital Crimes Litigation Act (repealed). This subsection
4 (n) shall apply until the conclusion of the trial of the
5 case, even if the prosecution chooses not to pursue the
6 death penalty prior to trial or sentencing.
7 (o) Information that is prohibited from being
8 disclosed under Section 4 of the Illinois Health and
9 Hazardous Substances Registry Act.
10 (p) Security portions of system safety program plans,
11 investigation reports, surveys, schedules, lists, data, or
12 information compiled, collected, or prepared by or for the
13 Department of Transportation under Sections 2705-300 and
14 2705-616 of the Department of Transportation Law of the
15 Civil Administrative Code of Illinois, the Northern
16 Illinois Transit Authority under Section 2.11 of the
17 Northern Illinois Transit Authority Act, or the St. Clair
18 County Transit District under the Bi-State Transit Safety
19 Act (repealed).
20 (q) Information prohibited from being disclosed by the
21 Personnel Record Review Act.
22 (r) Information prohibited from being disclosed by the
23 Illinois School Student Records Act.
24 (s) Information the disclosure of which is restricted
25 under Section 5-108 of the Public Utilities Act.
26 (t) (Blank).
SB3365 Enrolled - 72 - LRB104 18483 SSS 31925 b
1 (u) Records and information provided to an independent
2 team of experts under the Developmental Disability and
3 Mental Health Safety Act (also known as Brian's Law).
4 (v) Names and information of people who have applied
5 for or received Firearm Owner's Identification Cards under
6 the Firearm Owners Identification Card Act or applied for
7 or received a concealed carry license under the Firearm
8 Concealed Carry Act, unless otherwise authorized by the
9 Firearm Concealed Carry Act; and databases under the
10 Firearm Concealed Carry Act, records of the Concealed
11 Carry Licensing Review Board under the Firearm Concealed
12 Carry Act, and law enforcement agency objections under the
13 Firearm Concealed Carry Act.
14 (v-5) Records of the Firearm Owner's Identification
15 Card Review Board that are exempted from disclosure under
16 Section 10 of the Firearm Owners Identification Card Act.
17 (w) Personally identifiable information which is
18 exempted from disclosure under subsection (g) of Section
19 19.1 of the Toll Highway Act.
20 (x) Information which is exempted from disclosure
21 under Section 5-1014.3 of the Counties Code or Section
22 8-11-21 of the Illinois Municipal Code.
23 (y) Confidential information under the Adult
24 Protective Services Act and its predecessor enabling
25 statute, the Elder Abuse and Neglect Act, including
26 information about the identity and administrative finding
SB3365 Enrolled - 73 - LRB104 18483 SSS 31925 b
1 against any caregiver of a verified and substantiated
2 decision of abuse, neglect, or financial exploitation of
3 an eligible adult maintained in the Registry established
4 under Section 7.5 of the Adult Protective Services Act.
5 (z) Records and information provided to a fatality
6 review team or the Illinois Fatality Review Team Advisory
7 Council under Section 15 of the Adult Protective Services
8 Act.
9 (aa) Information which is exempted from disclosure
10 under Section 2.37 of the Wildlife Code.
11 (bb) Information which is or was prohibited from
12 disclosure by the Juvenile Court Act of 1987.
13 (cc) Recordings made under the Law Enforcement
14 Officer-Worn Body Camera Act, except to the extent
15 authorized under that Act.
16 (dd) Information that is prohibited from being
17 disclosed under Section 45 of the Condominium and Common
18 Interest Community Ombudsperson Act.
19 (ee) Information that is exempted from disclosure
20 under Section 30.1 of the Pharmacy Practice Act.
21 (ff) Information that is exempted from disclosure
22 under the Revised Uniform Unclaimed Property Act.
23 (gg) Information that is prohibited from being
24 disclosed under Section 7-603.5 of the Illinois Vehicle
25 Code.
26 (hh) Records that are exempt from disclosure under
SB3365 Enrolled - 74 - LRB104 18483 SSS 31925 b
1 Section 1A-16.7 of the Election Code.
2 (ii) Information which is exempted from disclosure
3 under Section 2505-800 of the Department of Revenue Law of
4 the Civil Administrative Code of Illinois.
5 (jj) Information and reports that are required to be
6 submitted to the Department of Labor by registering day
7 and temporary labor service agencies but are exempt from
8 disclosure under subsection (a-1) of Section 45 of the Day
9 and Temporary Labor Services Act.
10 (kk) Information prohibited from disclosure under the
11 Seizure and Forfeiture Reporting Act.
12 (ll) Information the disclosure of which is restricted
13 and exempted under Section 5-30.8 of the Illinois Public
14 Aid Code.
15 (mm) Records that are exempt from disclosure under
16 Section 4.2 of the Crime Victims Compensation Act.
17 (nn) Information that is exempt from disclosure under
18 Section 70 of the Higher Education Student Assistance Act.
19 (oo) Communications, notes, records, and reports
20 arising out of a peer support counseling session
21 prohibited from disclosure under the First Responders
22 Suicide Prevention Act.
23 (pp) Names and all identifying information relating to
24 an employee of an emergency services provider or law
25 enforcement agency under the First Responders Suicide
26 Prevention Act.
SB3365 Enrolled - 75 - LRB104 18483 SSS 31925 b
1 (qq) Information and records held by the Department of
2 Public Health and its authorized representatives collected
3 under the Reproductive Health Act.
4 (rr) Information that is exempt from disclosure under
5 the Cannabis Regulation and Tax Act.
6 (ss) Data reported by an employer to the Department of
7 Human Rights pursuant to Section 2-108 of the Illinois
8 Human Rights Act.
9 (tt) Recordings made under the Children's Advocacy
10 Center Act, except to the extent authorized under that
11 Act.
12 (uu) Information that is exempt from disclosure under
13 Section 50 of the Sexual Assault Evidence Submission Act.
14 (vv) Information that is exempt from disclosure under
15 subsections (f) and (j) of Section 5-36 of the Illinois
16 Public Aid Code.
17 (ww) Information that is exempt from disclosure under
18 Section 16.8 of the State Treasurer Act.
19 (xx) Information that is exempt from disclosure or
20 information that shall not be made public under the
21 Illinois Insurance Code.
22 (yy) Information prohibited from being disclosed under
23 the Illinois Educational Labor Relations Act.
24 (zz) Information prohibited from being disclosed under
25 the Illinois Public Labor Relations Act.
26 (aaa) Information prohibited from being disclosed
SB3365 Enrolled - 76 - LRB104 18483 SSS 31925 b
1 under Section 1-167 of the Illinois Pension Code.
2 (bbb) Information that is prohibited from disclosure
3 by the Illinois Police Training Act and the Illinois State
4 Police Act.
5 (ccc) Records exempt from disclosure under Section
6 2605-304 of the Illinois State Police Law of the Civil
7 Administrative Code of Illinois.
8 (ddd) Information prohibited from being disclosed
9 under Section 35 of the Address Confidentiality for
10 Victims of Domestic Violence, Sexual Assault, Human
11 Trafficking, or Stalking Act.
12 (eee) Information prohibited from being disclosed
13 under subsection (b) of Section 75 of the Domestic
14 Violence Fatality Review Act.
15 (fff) Images from cameras under the Expressway Camera
16 Act and all automated license plate reader (ALPR)
17 information used and collected by the Illinois State
18 Police. "ALPR information" means information gathered by
19 an ALPR or created from the analysis of data generated by
20 an ALPR. This subsection (fff) is inoperative on and after
21 July 1, 2028.
22 (ggg) Information prohibited from disclosure under
23 paragraph (3) of subsection (a) of Section 14 of the Nurse
24 Agency Licensing Act.
25 (hhh) Information submitted to the Illinois State
26 Police in an affidavit or application for an assault
SB3365 Enrolled - 77 - LRB104 18483 SSS 31925 b
1 weapon endorsement, assault weapon attachment endorsement,
2 .50 caliber rifle endorsement, or .50 caliber cartridge
3 endorsement under the Firearm Owners Identification Card
4 Act.
5 (iii) Data exempt from disclosure under Section 50 of
6 the School Safety Drill Act.
7 (jjj) Information exempt from disclosure under Section
8 30 of the Insurance Data Security Law.
9 (kkk) Confidential business information prohibited
10 from disclosure under Section 45 of the Paint Stewardship
11 Act.
12 (lll) Data exempt from disclosure under Section
13 2-3.196 of the School Code.
14 (mmm) Information prohibited from being disclosed
15 under subsection (e) of Section 1-129 of the Illinois
16 Power Agency Act.
17 (nnn) Materials received by the Department of Commerce
18 and Economic Opportunity that are confidential under the
19 Music and Musicians Tax Credit and Jobs Act.
20 (ooo) Data or information provided pursuant to Section
21 20 of the Statewide Recycling Needs and Assessment Act.
22 (ppp) Information that is exempt from disclosure under
23 Section 28-11 of the Lawful Health Care Activity Act.
24 (qqq) Information that is exempt from disclosure under
25 Section 7-101 of the Illinois Human Rights Act.
26 (rrr) Information prohibited from being disclosed
SB3365 Enrolled - 78 - LRB104 18483 SSS 31925 b
1 under Section 4-2 of the Uniform Money Transmission
2 Modernization Act.
3 (sss) Information exempt from disclosure under Section
4 40 of the Student-Athlete Endorsement Rights Act.
5 (ttt) Audio recordings made under Section 30 of the
6 Illinois State Police Act, except to the extent authorized
7 under that Section.
8 (uuu) Information prohibited from being disclosed
9 under Section 30-5 of the Digital Assets Regulation Act.
10 (vvv) (uuu) Information exempt from disclosure under
11 Section 70 of the End-of-Life Options for Terminally Ill
12 Patients Act.
13 (www) Annual summary financial and utilization data
14 reports submitted to the Health Facilities and Services
15 Review Board under Section 13 of the Illinois Health
16 Facilities Planning Act.
17 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
18 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
19 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
20 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
21 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
22 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
23 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
24 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-441, eff.
25 9-12-26; 104-457, eff. 6-1-26; revised 1-7-26.)
SB3365 Enrolled - 79 - LRB104 18483 SSS 31925 b
1 Section 6-75. The Illinois Health Facilities Planning Act
2 is amended by changing Sections 2 and 13 as follows:
3 (20 ILCS 3960/2) (from Ch. 111 1/2, par. 1152)
4 (Section scheduled to be repealed on December 31, 2029)
5 Sec. 2. Purpose of the Act. This Act shall establish a
6 procedure (1) which requires a person establishing,
7 constructing or modifying a health care facility, as herein
8 defined, to have the qualifications, background, character and
9 financial resources to adequately provide a proper service for
10 the community; (2) that promotes the orderly and economic
11 development of health care facilities in the State of Illinois
12 that avoids unnecessary duplication of such facilities; and
13 (3) that promotes planning for and development of health care
14 facilities needed for comprehensive health care especially in
15 areas where the health planning process has identified unmet
16 needs.
17 The changes made to this Act by this amendatory Act of the
18 96th General Assembly are intended to accomplish the following
19 objectives: to improve the financial ability of the public to
20 obtain necessary health services; to establish an orderly and
21 comprehensive health care delivery system that will guarantee
22 the availability of quality health care to the general public;
23 to maintain and improve the provision of essential health care
24 services and increase the accessibility of those services to
25 the medically underserved and indigent; to assure that the
SB3365 Enrolled - 80 - LRB104 18483 SSS 31925 b
1 reduction and closure of health care services or facilities is
2 performed in an orderly and timely manner, and that these
3 actions are deemed to be in the best interests of the public;
4 and to assess the financial burden to patients caused by
5 unnecessary health care construction and modification.
6 Evidence-based assessments, projections and decisions will be
7 applied regarding capacity, quality, value and equity in the
8 delivery of health care services in Illinois. The integrity of
9 the Certificate of Need process is ensured through revised
10 ethics and communications procedures. Cost containment and
11 support for safety net services must continue to be central
12 tenets of the Certificate of Need process.
13 The changes made to this Act by this amendatory Act of the
14 104th General Assembly are intended to allow the State to
15 collect additional information regarding the financial ability
16 for health care facilities to deliver services in Illinois.
17 (Source: P.A. 99-527, eff. 1-1-17.)
18 (20 ILCS 3960/13) (from Ch. 111 1/2, par. 1163)
19 (Section scheduled to be repealed on December 31, 2029)
20 Sec. 13. Investigation of applications for permits.
21 (a) Investigations. The State Board shall make or cause to
22 be made such investigations as it deems necessary in
23 connection with an application for a permit, or in connection
24 with a determination of whether or not construction or
25 modification that has been commenced is in accord with the
SB3365 Enrolled - 81 - LRB104 18483 SSS 31925 b
1 permit issued by the State Board, or whether construction or
2 modification has been commenced without a permit having been
3 obtained. The State Board may issue subpoenas duces tecum
4 requiring the production of records and may administer oaths
5 to such witnesses.
6 Any circuit court of this State, upon the application of
7 the State Board or upon the application of any party to such
8 proceedings, may, in its discretion, compel the attendance of
9 witnesses, the production of books, papers, records, or
10 memoranda and the giving of testimony before the State Board,
11 by a proceeding as for contempt, or otherwise, in the same
12 manner as production of evidence may be compelled before the
13 court.
14 (b) Reports from health facilities. The State Board shall
15 require all health facilities operating in this State to
16 provide such reasonable reports at such times and containing
17 such information as is needed by it to carry out the purposes
18 and provisions of this Act. Prior to collecting information
19 from health facilities, the State Board shall make reasonable
20 efforts through a public process to consult with health
21 facilities and associations that represent them to determine
22 whether data and information requests will result in useful
23 information for health planning, whether sufficient
24 information is available from other sources, and whether data
25 requested is routinely collected by health facilities and is
26 available without retrospective record review. Data and
SB3365 Enrolled - 82 - LRB104 18483 SSS 31925 b
1 information requests shall not impose undue paperwork burdens
2 on health care facilities and personnel. Health facilities not
3 complying with this requirement shall be reported to
4 licensing, accrediting, certifying, or payment agencies as
5 being in violation of State law. Health care facilities and
6 other parties at interest shall have reasonable access, under
7 rules established by the State Board, to all planning
8 information submitted in accord with this Act pertaining to
9 their area.
10 (1) Questionnaires. Among the reports to be required
11 by the State Board are facility questionnaires for health
12 care facilities licensed under the Ambulatory Surgical
13 Treatment Center Act, the Hospital Licensing Act, the
14 Nursing Home Care Act, the ID/DD Community Care Act, the
15 MC/DD Act, or the Specialized Mental Health Rehabilitation
16 Act of 2013 and health care facilities that are required
17 to meet the requirements of 42 CFR 494 in order to be
18 certified for participation in Medicare and Medicaid under
19 Titles XVIII and XIX of the federal Social Security Act.
20 These questionnaires shall be conducted on an annual basis
21 and compiled by the State Board. For health care
22 facilities licensed under the Nursing Home Care Act or the
23 Specialized Mental Health Rehabilitation Act of 2013,
24 these reports shall include, but not be limited to, the
25 identification of specialty services provided by the
26 facility to patients, residents, and the community at
SB3365 Enrolled - 83 - LRB104 18483 SSS 31925 b
1 large. Annual reports for facilities licensed under the
2 ID/DD Community Care Act and facilities licensed under the
3 MC/DD Act shall be different from the annual reports
4 required of other health care facilities and shall be
5 specific to those facilities licensed under the ID/DD
6 Community Care Act or the MC/DD Act. The Health Facilities
7 and Services Review Board shall consult with associations
8 representing facilities licensed under the ID/DD Community
9 Care Act and associations representing facilities licensed
10 under the MC/DD Act when developing the information
11 requested in these annual reports. For health care
12 facilities that contain long term care beds, the reports
13 shall also include the number of staffed long term care
14 beds, physical capacity for long term care beds at the
15 facility, and long term care beds available for immediate
16 occupancy. For purposes of this paragraph, "long term care
17 beds" means beds (i) licensed under the Nursing Home Care
18 Act, (ii) licensed under the ID/DD Community Care Act,
19 (iii) licensed under the MC/DD Act, (iv) licensed under
20 the Hospital Licensing Act, or (v) licensed under the
21 Specialized Mental Health Rehabilitation Act of 2013 and
22 certified as skilled nursing or nursing facility beds
23 under Medicaid or Medicare.
24 For health care facilities licensed under the Hospital
25 Licensing Act, the health care facilities operating in
26 this State shall report the following financial and
SB3365 Enrolled - 84 - LRB104 18483 SSS 31925 b
1 utilization data annually: (i) the most recent audited
2 financial statements; (ii) the most recent month-end
3 balance sheet detailing the assets, liabilities, and net
4 worth at the end of the month immediately preceding the
5 annual reporting cycle; (iii) the most recent income
6 statement for the month immediately preceding the annual
7 reporting cycle summarizing the revenues, expenses, and
8 net income; (iv) the total number of inpatient days,
9 outpatient visits, and discharges by payer, including, but
10 not limited to, Medicare, Medicaid fee-for-service,
11 Medicaid managed care, commercial coverage, and other
12 payers; (v) the total inpatient gross revenues by payer,
13 including, but not limited to, Medicare, Medicaid
14 fee-for-service, Medicaid managed care, commercial
15 coverage, and other payers; and (vi) the total outpatient
16 gross revenues by payer, including, but not limited to,
17 Medicare, Medicaid fee-for-service, Medicaid managed care,
18 commercial coverage, and other payers. The transmission of
19 the financial and utilization data shall be due to the
20 State Board within 90 days after the effective date of
21 this amendatory Act of the 104th General Assembly, and
22 thereafter, the data shall be due annually on the regular
23 schedule set by the State Board for questionnaires. The
24 State Board, in coordination with the Department of
25 Healthcare and Family Services and the Department of
26 Public Health, shall administer the collection of the
SB3365 Enrolled - 85 - LRB104 18483 SSS 31925 b
1 financial and utilization data submitted under this
2 Section. The State Board may adopt any administrative
3 rules, including emergency rules, necessary to implement
4 this Section, including requesting additional information
5 or removing information from the reporting requirements.
6 If a health care facility has not filed the required
7 financial and utilization data within 90 days after the
8 close of the annual reporting period, the State Board
9 shall impose fines of not more than $5,000 per week for
10 failure to comply with the provisions of this Section.
11 (2) Confidentiality.
12 (A) The State Board shall keep confidential the
13 annual summary financial and utilization data report
14 submitted under this Section and all information in
15 the report as required by this Section. The financial
16 and utilization data shall remain confidential, is not
17 subject to subpoena, is not subject to discovery or
18 admissible as evidence in private civil litigation, is
19 not subject to disclosure under the Freedom of
20 Information Act, and must not be made public at any
21 time or used by the State Board or any other person,
22 except as provided in subparagraphs (B), (D), and (E)
23 of this paragraph (2).
24 (B) Notwithstanding subparagraph (A), the State
25 Board may:
26 (i) share the financial and utilization data
SB3365 Enrolled - 86 - LRB104 18483 SSS 31925 b
1 submitted under this Section with other State
2 agencies;
3 (ii) share the financial and utilization data
4 submitted under this Section with third-party
5 vendors or contractors of a State agency, federal
6 regulatory agencies, or law enforcement
7 authorities, if the recipient agrees to and
8 verifies in writing its legal authority to
9 maintain the confidentiality and privileged status
10 of the financial and utilization data;
11 (iii) enter into agreements governing the
12 sharing and use of information consistent with
13 this Section.
14 (C) Disclosure of the financial and utilization
15 data to the State Board and by the State Board under
16 this Section does not waive any applicable privilege
17 or claim of confidentiality in the report or
18 information.
19 (D) Notwithstanding the confidentiality
20 requirements of this Section or otherwise imposed by
21 State law, relevant State agencies may make public
22 financial and utilization data submitted under this
23 Section in an aggregated format that does not disclose
24 information or data attributed to any specific
25 facility.
26 (E) Notwithstanding the confidentiality
SB3365 Enrolled - 87 - LRB104 18483 SSS 31925 b
1 requirements of this Section, a State agency may
2 disclose the financial and utilization data submitted
3 under this Section with the written consent of the
4 hospital that submitted the report.
5 (Source: P.A. 100-681, eff. 8-3-18; 100-957, eff. 8-19-18;
6 101-81, eff. 7-12-19.)
7 Section 6-80. The Hospital Licensing Act is amended by
8 adding Section 4.8 as follows:
9 (210 ILCS 85/4.8 new)
10 Sec. 4.8. Additional licensing requirements.
11 (a) Hospital emergency and financial contingency plan. Any
12 hospital licensed under this Act that has outstanding debts to
13 the State in the form of tax arrears or that maintains debt
14 through the Distressed Hospital Loan Program or other Medicaid
15 advance payments shall submit to the Department a hospital
16 emergency and financial contingency plan for the rapid and
17 orderly resolution of finances and operations in the event of
18 material financial distress. The plan shall be submitted on an
19 annual basis until any outstanding assessment or advance
20 balances have been fully paid. The plan shall include, but not
21 be limited to, procedures for the safe and orderly transfer
22 and continuity of care for patients if closure of at least one
23 category of service, or a temporary suspension of such service
24 for any reason, were to occur. Potential events precipitating
SB3365 Enrolled - 88 - LRB104 18483 SSS 31925 b
1 closure or suspended services that shall be addressed in the
2 plan, include, but are not limited to: financial distress,
3 regulatory and compliance issues, operational or workforce
4 challenges, infrastructure and facility issues, emergency or
5 disaster related causes, and strategic organizational
6 decisions. The plan shall contemplate (i) the identification
7 of potential service area gaps created due to emergency
8 closure and suspension of services and (ii) the orderly
9 preservation and transfer of medical records in accordance
10 with the Medical Patient Rights Act, the Health Insurance
11 Portability and Accountability Act of 1996, and other
12 applicable medical privacy laws.
13 (b) Hospital emergency and financial contingency plans for
14 hospitals with multiple locations operating under a single
15 license. Any hospital licensed by the Department under Section
16 4.5 of this Act and required to submit a hospital emergency and
17 financial contingency plan shall submit a hospital emergency
18 and financial contingency plan as outlined in subsection (a)
19 considering each location, campus, or facility administered
20 under the license that could reasonably be affected.
21 (c) Annual filing. Hospital emergency and financial
22 contingency plans shall be filed with the Department no later
23 than 3 months after the effective date of this amendatory Act
24 of the 104th General Assembly. Hospital emergency and
25 financial contingency plans, or annual affirmations of
26 previously filed hospital emergency and financial contingency
SB3365 Enrolled - 89 - LRB104 18483 SSS 31925 b
1 plans, as outlined in this Section shall be submitted on an
2 annual basis as determined by the Department through
3 administrative rule.
4 (d) Penalties for noncompliance. The Department may impose
5 fines of not more than $500 per week for failure to comply with
6 the provisions of this Section.
7 (e) This Section is operative on and after January 1,
8 2027.
9 ARTICLE 10.
10 Section 10-5. The Rebuild Illinois Mental Health Workforce
11 Act is amended by changing Section 20-10 as follows:
12 (305 ILCS 66/20-10)
13 Sec. 20-10. Medicaid funding for community mental health
14 services. Medicaid funding for the specific community mental
15 health services listed in this Act shall be adjusted and paid
16 as set forth in this Act. Such payments shall be paid in
17 addition to the base Medicaid reimbursement rate and add-on
18 payment rates per service unit.
19 (a) The following payment adjustments shall begin on July
20 1, 2022 for State Fiscal Year 2023 and shall continue for every
21 State fiscal year thereafter.
22 (1) Individual Therapy Medicaid Payment rate for
23 services provided under the H0004 Code:
SB3365 Enrolled - 90 - LRB104 18483 SSS 31925 b
1 (A) The Medicaid total payment rate for individual
2 therapy provided by a qualified mental health
3 professional shall be increased by no less than $9 per
4 service unit.
5 (B) The Medicaid total payment rate for individual
6 therapy provided by a mental health professional shall
7 be increased by no less than $9 per service unit.
8 (2) Community Support - Individual Medicaid Payment
9 rate for services provided under the H2015 Code: All
10 community support - individual services shall be increased
11 by no less than $15 per service unit.
12 (3) Case Management Medicaid Add-on Payment for
13 services provided under the T1016 code: All case
14 management services rates shall be increased by no less
15 than $15 per service unit.
16 (4) Assertive Community Treatment Medicaid Add-on
17 Payment for services provided under the H0039 code: The
18 Medicaid total payment rate for assertive community
19 treatment services shall increase by no less than $8 per
20 service unit.
21 (b) (5) Medicaid user-based directed payments. The
22 following directed payments shall be paid to qualifying
23 providers for State Fiscal Year 2023 through State Fiscal Year
24 2026. This subsection does not prevent the Department from
25 making payments in future State fiscal years to correct errors
26 or omissions made in State Fiscal Year 2023 through State
SB3365 Enrolled - 91 - LRB104 18483 SSS 31925 b
1 Fiscal Year 2026 payments.
2 (1) (A) For each State fiscal year, a monthly directed
3 payment shall be paid to a community mental health
4 provider of community support team services based on the
5 number of Medicaid users of community support team
6 services documented by Medicaid fee-for-service and
7 managed care encounter claims delivered by that provider
8 in the base year. The Department of Healthcare and Family
9 Services shall make the monthly directed payment to each
10 provider entitled to directed payments under this Act by
11 no later than the last day of each month throughout each
12 State fiscal year.
13 (A) (i) The monthly directed payment for a
14 community support team provider shall be calculated as
15 follows: The sum total number of individual Medicaid
16 users of community support team services delivered by
17 that provider throughout the base year, multiplied by
18 $4,200 per Medicaid user, divided into 12 equal
19 monthly payments for the State fiscal year.
20 (B) (ii) As used in this subparagraph, "user"
21 means an individual who received at least 200 units of
22 community support team services (H2016) during the
23 base year.
24 (2) (B) For each State fiscal year, a monthly directed
25 payment shall be paid to each community mental health
26 provider of assertive community treatment services based
SB3365 Enrolled - 92 - LRB104 18483 SSS 31925 b
1 on the number of Medicaid users of assertive community
2 treatment services documented by Medicaid fee-for-service
3 and managed care encounter claims delivered by the
4 provider in the base year.
5 (A) (i) The monthly direct payment for an
6 assertive community treatment provider shall be
7 calculated as follows: The sum total number of
8 Medicaid users of assertive community treatment
9 services provided by that provider throughout the base
10 year, multiplied by $6,000 per Medicaid user, divided
11 into 12 equal monthly payments for that State fiscal
12 year.
13 (B) (ii) As used in this subparagraph, "user"
14 means an individual that received at least 300 units
15 of assertive community treatment services during the
16 base year.
17 (3) (C) The base year for directed payments under this
18 Section shall be calendar year 2019 for State Fiscal Year
19 2023 and State Fiscal Year 2024. For the State fiscal year
20 beginning on July 1, 2024, and for every State fiscal year
21 thereafter, the base year shall be the calendar year that
22 ended 18 months prior to the start of the State fiscal year
23 in which payments are made.
24 (b-5) (b) Subject to federal approval, a one-time directed
25 payment must be made in calendar year 2023 for community
26 mental health services provided by community mental health
SB3365 Enrolled - 93 - LRB104 18483 SSS 31925 b
1 providers. The one-time directed payment shall be for an
2 amount appropriated for these purposes. The one-time directed
3 payment shall be for services for Integrated Assessment and
4 Treatment Planning and other intensive services, including,
5 but not limited to, services for Mobile Crisis Response,
6 crisis intervention, and medication monitoring. The amounts
7 and services used for designing and distributing these
8 one-time directed payments shall not be construed to require
9 any future rate or funding increases for the same or other
10 mental health services.
11 (b-6) Subject to federal approval, for dates of service on
12 and after July 1, 2026, the Medicaid reimbursement rates for
13 Assertive Community Treatment and Community Support Team
14 services shall be increased by an amount no less than the
15 following targeted pools. The Department must use service
16 units delivered under the fee-for-service and managed care
17 programs by community mental health centers during State
18 Fiscal Year 2024 for distributing the targeted pools and
19 setting rates.
20 (1) Assertive Community Treatment, $10,600,000; and
21 (2) Community Support Team services, $17,500,000.
22 (c) The following payment adjustments shall be made:
23 (1) Subject to federal approval, beginning on January
24 1, 2024, the Department shall introduce rate increases to
25 behavioral health services no less than by the following
26 targeted pool for the specified services provided by
SB3365 Enrolled - 94 - LRB104 18483 SSS 31925 b
1 community mental health centers:
2 (A) Mobile Crisis Response, $6,800,000;
3 (B) Crisis Intervention, $4,000,000;
4 (C) Integrative Assessment and Treatment Planning
5 services, $10,500,000;
6 (D) Group Therapy, $1,200,000;
7 (E) Family Therapy, $500,000;
8 (F) Community Support Group, $4,000,000; and
9 (G) Medication Monitoring, $3,000,000.
10 (2) Rate increases shall be determined with
11 significant input from Illinois behavioral health trade
12 associations and advocates. The Department must use
13 service units delivered under the fee-for-service and
14 managed care programs by community mental health centers
15 during State Fiscal Year 2022. These services are used for
16 distributing the targeted pools and setting rates but do
17 not prohibit the Department from paying providers not
18 enrolled as community mental health centers the same rate
19 if providing the same services.
20 (d) Rate simplification for team-based services.
21 (1) The Department shall work with stakeholders to
22 redesign reimbursement rates for behavioral health
23 team-based services established under the Rehabilitation
24 Option of the Illinois Medicaid State Plan supporting
25 individuals with chronic or complex behavioral health
26 conditions and crisis services. Subject to federal
SB3365 Enrolled - 95 - LRB104 18483 SSS 31925 b
1 approval, the redesigned rates shall seek to introduce
2 bundled payment systems that minimize provider claiming
3 activities while transitioning the focus of treatment
4 towards metrics and outcomes. Federally approved rate
5 models shall seek to ensure reimbursement levels are no
6 less than the State's total reimbursement for similar
7 services in calendar year 2023, including all service
8 level payments, add-ons, and all other payments specified
9 in this Section.
10 (2) In State Fiscal Year 2024, the Department shall
11 identify an existing, or establish a new, Behavioral
12 Health Outcomes Stakeholder Workgroup to help inform the
13 identification of metrics and outcomes for team-based
14 services.
15 (3) In State Fiscal Year 2025, subject to federal
16 approval, the Department shall introduce a
17 pay-for-performance model for team-based services to be
18 informed by the Behavioral Health Outcomes Stakeholder
19 Workgroup.
20 (Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
21 103-102, eff. 7-1-23; 103-154, eff. 6-30-23.)
22 ARTICLE 15.
23 Section 15-5. The State Finance Act is amended by changing
24 Section 5.945 as follows:
SB3365 Enrolled - 96 - LRB104 18483 SSS 31925 b
1 (30 ILCS 105/5.945)
2 Sec. 5.945. The Medicaid Technical Assistance Center Fund.
3 Notwithstanding any other provision of law, in addition to any
4 other transfers that may be provided by law, on July 1, 2026,
5 or as soon thereafter as practical, the State Comptroller
6 shall direct and the State Treasurer shall transfer the
7 remaining balance from the Medicaid Technical Assistance
8 Center Fund into the Healthcare Provider Relief Fund. Upon
9 completion of the transfers, the Medicaid Technical Assistance
10 Center Fund is dissolved, and any future deposits due to that
11 Fund and any outstanding obligations or liabilities of that
12 Fund pass to the Healthcare Provider Relief Fund.
13 (Source: P.A. 102-4, Article 185, Section 185-90, eff.
14 4-27-21; 102-813, eff. 5-13-22.)
15 Section 15-10. The Medicaid Technical Assistance Act is
16 amended by changing Sections 185-5 and 185-15 as follows:
17 (305 ILCS 75/185-5)
18 Sec. 185-5. Definitions. As used in this Act:
19 "Behavioral health providers" includes providers of mental
20 health, substance use disorder, developmental disabilities,
21 and autism services for purposes of this Act, but does not
22 change any other legal, programmatic, diagnostic, or clinical
23 provisions defining or relating to coverage of such services.
SB3365 Enrolled - 97 - LRB104 18483 SSS 31925 b
1 means mental health and substance use disorder providers.
2 "Department" means the Department of Healthcare and Family
3 Services.
4 "Health care providers" means individuals and
5 organizations that who provide physical, mental, or substance
6 use disorder services, or services supporting social
7 determinants determinant of health services.
8 "Health equity" means providing care that does not vary in
9 quality because of personal characteristics such as gender,
10 ethnicity, geographic location, and socioeconomic status.
11 "Network adequacy" means a Medicaid beneficiaries' ability
12 to access all necessary provider types within time and
13 distance standards as defined in the Managed Care Organization
14 model contract.
15 "Service deserts" means geographic areas of the State with
16 no or limited Medicaid providers that accept Medicaid.
17 "Social determinants of health" means any conditions that
18 impact an individual's health, including, but not limited to,
19 access to healthy food, safety, education, and housing
20 stability.
21 "Stakeholders" means, but are not limited to, health care
22 providers, advocacy organizations, managed care organizations,
23 Medicaid beneficiaries, and State and city partners.
24 (Source: P.A. 102-4, eff. 4-27-21.)
25 (305 ILCS 75/185-15)
SB3365 Enrolled - 98 - LRB104 18483 SSS 31925 b
1 Sec. 185-15. Collaboration. The Medicaid Technical
2 Assistance Center shall collaborate with public and private
3 partners throughout the State to identify, establish, and
4 maintain best practices necessary for health providers to
5 ensure their capacity to participate in the Illinois Medical
6 Assistance Program. The Medicaid Technical Assistance Center
7 shall promote equitable delivery systems, remaining committed
8 to the principle that all Medicaid recipients have accessible
9 and equitable physical and mental health care services
10 HealthChoice Illinois or YouthCare. The Medicaid Technical
11 Assistance Center shall administer the following:
12 (1) Outreach and engagement: The Medicaid Technical
13 Assistance Center shall undertake efforts to identify and
14 engage community-based providers offering services to
15 customers funded by the Department, including, but not
16 limited to, behavioral health services and or services
17 addressing the social determinants of health, especially
18 those predominantly serving communities of color or those
19 operating within or near service deserts, for the purpose
20 of offering training and technical assistance to them
21 through the Medicaid Technical Assistance Center. Outreach
22 and engagement services may be subcontracted.
23 (2) Trainings: The Medicaid Technical Assistance
24 Center shall create and administer ongoing trainings for
25 health care providers. Trainings may be subcontracted. The
26 Medicaid Technical Assistance Center shall provide
SB3365 Enrolled - 99 - LRB104 18483 SSS 31925 b
1 in-person and web-based trainings. In-person training
2 shall be conducted throughout the State. All trainings
3 must be free of charge. The Medicaid Technical Assistance
4 Center shall administer post-training surveys and
5 incorporate feedback. Training content and delivery must
6 be reflective of Illinois providers' varying levels of
7 readiness, resources, and client populations.
8 (3) Web-based resources: The Medicaid Technical
9 Assistance Center shall maintain an independent, easy to
10 navigate, and up-to-date website that includes, but is not
11 limited to: recorded training archives, a training
12 calendar, provider resources and tools, up-to-date
13 explanations of Department and managed care organization
14 guidance, a running database of frequently asked questions
15 and contact information for key staff members of the
16 Department, managed care organizations, and the Medicaid
17 Technical Assistance Center.
18 (4) Learning collaboratives: The Medicaid Technical
19 Assistance Center shall host regional learning
20 collaboratives that will supplement the Medicaid Technical
21 Assistance Center training curriculum to bring together
22 groups of stakeholders to share issues and best practices,
23 and to escalate issues. Leadership of the Department and
24 managed care organizations shall attend learning
25 collaboratives on a quarterly basis.
26 (5) Network recruitment plan: Using reports and data
SB3365 Enrolled - 100 - LRB104 18483 SSS 31925 b
1 provided by the Department's External Quality Review
2 Organization on adequacy reports: The Medicaid Technical
3 Assistance Center shall publicly release a report on
4 Medicaid provider network adequacy, within the first 3
5 years of implementation and annually thereafter. The
6 reports shall identify provider service deserts, and
7 health care disparities by race and ethnicity, the
8 Medicaid Technical Assistance Center shall propose for
9 Department review and approval an annual plan for
10 recruiting providers to participate in the Illinois
11 Medical Assistance Program and report on outcomes of its
12 recruitment efforts to the Department for continuous
13 improvement. Recruitment plans shall prioritize efforts to
14 bolster access in provider service deserts and in
15 communities experiencing health care disparities by race
16 and ethnicity, with a special focus on behavioral health
17 services and services that address social determinants of
18 health.
19 (6) Equitable delivery system: The Medicaid Technical
20 Assistance Center is committed to the principle that all
21 Medicaid recipients have accessible and equitable physical
22 and mental health care services. All providers served
23 through the Medicaid Technical Assistance Center shall
24 deliver services notwithstanding the patient's race,
25 color, gender, gender identity, age, ancestry, marital
26 status, military status, religion, national origin,
SB3365 Enrolled - 101 - LRB104 18483 SSS 31925 b
1 disability status, sexual orientation, order of protection
2 status, as defined under Section 1-103 of the Illinois
3 Human Rights Act, or immigration status.
4 (Source: P.A. 102-4, eff. 4-27-21.)
5 (305 ILCS 75/185-20 rep.)
6 (305 ILCS 75/185-25 rep.)
7 Section 15-15. The Medicaid Technical Assistance Act is
8 amended by repealing Sections 185-20 and 185-25.
9 ARTICLE 20.
10 Section 20-5. The Illinois Public Aid Code is amended by
11 changing Section 5-5f as follows:
12 (305 ILCS 5/5-5f)
13 Sec. 5-5f. Elimination and limitations of medical
14 assistance services. Notwithstanding any other provision of
15 this Code to the contrary, on and after July 1, 2012:
16 (a) The following service shall no longer be a covered
17 service available under this Code: group psychotherapy for
18 residents of any facility licensed under the Nursing Home
19 Care Act or the Specialized Mental Health Rehabilitation
20 Act of 2013.
21 (b) The Department shall place the following
22 limitations on services: (i) the Department shall limit
SB3365 Enrolled - 102 - LRB104 18483 SSS 31925 b
1 adult eyeglasses to one pair every 2 years; however, the
2 limitation does not apply to an individual who needs
3 different eyeglasses following a surgical procedure such
4 as cataract surgery; (ii) the Department shall set an
5 annual limit of a maximum of 20 visits for each of the
6 following services: adult speech, hearing, and language
7 therapy services, adult occupational therapy services, and
8 physical therapy services; on or after October 1, 2014,
9 the annual maximum limit of 20 visits shall expire but the
10 Department may require prior approval for all individuals
11 for speech, hearing, and language therapy services,
12 occupational therapy services, and physical therapy
13 services; (iii) the Department shall limit adult podiatry
14 services to individuals with diabetes; on or after October
15 1, 2014, podiatry services shall not be limited to
16 individuals with diabetes; (iv) the Department shall pay
17 for caesarean sections at the normal vaginal delivery rate
18 unless a caesarean section was medically necessary; (v)
19 the Department shall limit adult dental services to
20 emergencies; beginning July 1, 2013, the Department shall
21 ensure that the following conditions are recognized as
22 emergencies: (A) dental services necessary for an
23 individual in order for the individual to be cleared for a
24 medical procedure, such as a transplant; (B) extractions
25 and dentures necessary for a diabetic to receive proper
26 nutrition; (C) extractions and dentures necessary as a
SB3365 Enrolled - 103 - LRB104 18483 SSS 31925 b
1 result of cancer treatment; and (D) dental services
2 necessary for the health of a pregnant woman prior to
3 delivery of her baby; on or after July 1, 2014, adult
4 dental services shall no longer be limited to emergencies,
5 and dental services necessary for the health of a pregnant
6 woman prior to delivery of her baby shall continue to be
7 covered; and (vi) effective July 1, 2012 through June 30,
8 2021, the Department shall place limitations and require
9 concurrent review on every inpatient detoxification stay
10 to prevent repeat admissions to any hospital for
11 detoxification within 60 days of a previous inpatient
12 detoxification stay. The Department shall convene a
13 workgroup of hospitals, substance abuse providers, care
14 coordination entities, managed care plans, and other
15 stakeholders to develop recommendations for quality
16 standards, diversion to other settings, and admission
17 criteria for patients who need inpatient detoxification,
18 which shall be published on the Department's website no
19 later than September 1, 2013.
20 (c) The Department shall require prior approval of the
21 following services: wheelchair repairs costing more than
22 $750, coronary artery bypass graft, and bariatric surgery
23 consistent with Medicare standards concerning patient
24 responsibility. Wheelchair repair prior approval requests
25 shall be adjudicated within one business day of receipt of
26 complete supporting documentation. Providers may not break
SB3365 Enrolled - 104 - LRB104 18483 SSS 31925 b
1 wheelchair repairs into separate claims for purposes of
2 staying under the $750 threshold for requiring prior
3 approval. The wholesale price of manual and power
4 wheelchairs, durable medical equipment and supplies, and
5 complex rehabilitation technology products and services
6 shall be defined as actual acquisition cost including all
7 discounts.
8 (d) (Blank). The Department shall establish benchmarks
9 for hospitals to measure and align payments to reduce
10 potentially preventable hospital readmissions, inpatient
11 complications, and unnecessary emergency room visits. In
12 doing so, the Department shall consider items, including,
13 but not limited to, historic and current acuity of care
14 and historic and current trends in readmission. The
15 Department shall publish provider-specific historical
16 readmission data and anticipated potentially preventable
17 targets 60 days prior to the start of the program. In the
18 instance of readmissions, the Department shall adopt
19 policies and rates of reimbursement for services and other
20 payments provided under this Code to ensure that, by June
21 30, 2013, expenditures to hospitals are reduced by, at a
22 minimum, $40,000,000.
23 (e) The Department shall establish utilization
24 controls for the hospice program such that it shall not
25 pay for other care services when an individual is in
26 hospice.
SB3365 Enrolled - 105 - LRB104 18483 SSS 31925 b
1 (f) For home health services, the Department shall
2 require Medicare certification of providers participating
3 in the program and implement the Medicare face-to-face
4 encounter rule. The Department shall require providers to
5 implement auditable electronic service verification based
6 on global positioning systems or other cost-effective
7 technology.
8 (g) For the Home Services Program operated by the
9 Department of Human Services and the Community Care
10 Program operated by the Department on Aging, the
11 Department of Human Services, in cooperation with the
12 Department on Aging, shall implement an electronic service
13 verification based on global positioning systems or other
14 cost-effective technology.
15 (h) Effective with inpatient hospital admissions on or
16 after July 1, 2012, the Department shall reduce the
17 payment for a claim that indicates the occurrence of a
18 provider-preventable condition during the admission as
19 specified by the Department in rules. The Department shall
20 not pay for services related to an other
21 provider-preventable condition.
22 As used in this subsection (h):
23 "Provider-preventable condition" means a health care
24 acquired condition as defined under the federal Medicaid
25 regulation found at 42 CFR 447.26 or an other
26 provider-preventable condition.
SB3365 Enrolled - 106 - LRB104 18483 SSS 31925 b
1 "Other provider-preventable condition" means a wrong
2 surgical or other invasive procedure performed on a
3 patient, a surgical or other invasive procedure performed
4 on the wrong body part, or a surgical procedure or other
5 invasive procedure performed on the wrong patient.
6 (i) The Department shall implement cost savings
7 initiatives for advanced imaging services, cardiac imaging
8 services, pain management services, and back surgery. Such
9 initiatives shall be designed to achieve annual costs
10 savings.
11 (j) The Department shall ensure that beneficiaries
12 with a diagnosis of epilepsy or seizure disorder in
13 Department records will not require prior approval for
14 anticonvulsants.
15 (Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section
16 5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff.
17 7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21;
18 102-813, eff. 5-13-22.)
19 ARTICLE 25.
20 Section 25-5. The Illinois Public Aid Code is amended by
21 changing Section 14-12 as follows:
22 (305 ILCS 5/14-12)
23 Sec. 14-12. Hospital rate reform payment system. The
SB3365 Enrolled - 107 - LRB104 18483 SSS 31925 b
1 hospital payment system pursuant to Section 14-11 of this
2 Article shall be as follows:
3 (a) Inpatient hospital services. Effective on and after
4 the effective date of this amendatory Act of the 104th General
5 Assembly, reimbursement for inpatient general acute care
6 services shall utilize the All Patient Refined Diagnosis
7 Related Grouping (APR-DRG) software distributed by SolventumTM
8 previously known as 3MTM Health Information System. SolventumTM
9 shall be the exclusive provider of this software unless the
10 Department determines that SolventumTM is unable to meet the
11 required operational or contractual terms. Only under these
12 circumstances may an alternative authorized provider of the
13 software be considered.
14 (1) The Department shall establish Medicaid weighting
15 factors to be used in the reimbursement system established
16 under this subsection. Initial weighting factors shall be
17 the weighting factors as published by the authorized
18 provider of this software adjusted for the Illinois
19 experience.
20 (2) The Department shall establish a
21 statewide-standardized amount to be used in the inpatient
22 reimbursement system. The Department shall publish these
23 amounts on its website no later than 10 calendar days
24 prior to their effective date.
25 (3) In addition to the statewide-standardized amount,
26 the Department shall develop adjusters to adjust the rate
SB3365 Enrolled - 108 - LRB104 18483 SSS 31925 b
1 of reimbursement for critical Medicaid providers or
2 services for trauma, transplantation services, perinatal
3 care, and Graduate Medical Education (GME).
4 (4) The Department shall develop add-on payments to
5 account for exceptionally costly inpatient stays,
6 consistent with Medicare outlier principles. Outlier fixed
7 loss thresholds may be updated to control for excessive
8 growth in outlier payments no more frequently than on an
9 annual basis, but at least once every 4 years. Upon
10 updating the fixed loss thresholds, the Department shall
11 be required to update base rates within 12 months.
12 (5) The Department shall define those hospitals or
13 distinct parts of hospitals that shall be exempt from the
14 APR-DRG reimbursement system established under this
15 Section. The Department shall publish these hospitals'
16 inpatient rates on its website no later than 10 calendar
17 days prior to their effective date.
18 (6) Beginning July 1, 2014 and ending on December 31,
19 2023, in addition to the statewide-standardized amount,
20 the Department shall develop an adjustor to adjust the
21 rate of reimbursement for safety-net hospitals defined in
22 Section 5-5e.1 of this Code excluding pediatric hospitals.
23 (7) Beginning July 1, 2014, in addition to the
24 statewide-standardized amount, the Department shall
25 develop an adjustor to adjust the rate of reimbursement
26 for Illinois freestanding inpatient psychiatric hospitals
SB3365 Enrolled - 109 - LRB104 18483 SSS 31925 b
1 that are not designated as children's hospitals by the
2 Department but are primarily treating patients under the
3 age of 21.
4 (7.5) (Blank).
5 (8) Beginning July 1, 2018, in addition to the
6 statewide-standardized amount, the Department shall adjust
7 the rate of reimbursement for hospitals designated by the
8 Department of Public Health as a Perinatal Level II or II+
9 center by applying the same adjustor that is applied to
10 Perinatal and Obstetrical care cases for Perinatal Level
11 III centers, as of December 31, 2017.
12 (9) Beginning July 1, 2018, in addition to the
13 statewide-standardized amount, the Department shall apply
14 the same adjustor that is applied to trauma cases as of
15 December 31, 2017 to inpatient claims to treat patients
16 with burns, including, but not limited to, APR-DRGs 841,
17 842, 843, and 844.
18 (10) Beginning July 1, 2018, the
19 statewide-standardized amount for inpatient general acute
20 care services shall be uniformly increased so that base
21 claims projected reimbursement is increased by an amount
22 equal to the funds allocated in paragraph (1) of
23 subsection (b) of Section 5A-12.6, less the amount
24 allocated under paragraphs (8) and (9) of this subsection
25 and paragraphs (3) and (4) of subsection (b) multiplied by
26 40%.
SB3365 Enrolled - 110 - LRB104 18483 SSS 31925 b
1 (11) Beginning July 1, 2018, the reimbursement for
2 inpatient rehabilitation services shall be increased by
3 the addition of a $96 per day add-on.
4 (b) Outpatient hospital services. Effective on and after
5 the effective date of this amendatory Act of the 104th General
6 Assembly, reimbursement for outpatient services shall utilize
7 the Enhanced Ambulatory Procedure Grouping (EAPG) software
8 distributed by SolventumTM previously known as 3MTM Health
9 Information System. SolventumTM shall be the exclusive
10 provider of this software unless the Agency determines that
11 SolventumTM is unable to meet the required operational or
12 contractual terms. Only under these circumstances may an
13 alternative authorized provider of the software be considered.
14 (1) The Department shall establish Medicaid weighting
15 factors to be used in the reimbursement system established
16 under this subsection. The initial weighting factors shall
17 be the weighting factors as published by the authorized
18 provider.
19 (2) The Department shall establish service specific
20 statewide-standardized amounts to be used in the
21 reimbursement system.
22 (A) The initial statewide standardized amounts,
23 with the labor portion adjusted by the Calendar Year
24 2013 Medicare Outpatient Prospective Payment System
25 wage index with reclassifications, shall be published
26 by the Department on its website no later than 10
SB3365 Enrolled - 111 - LRB104 18483 SSS 31925 b
1 calendar days prior to their effective date.
2 (B) The Department shall establish adjustments to
3 the statewide-standardized amounts for each Critical
4 Access Hospital, as designated by the Department of
5 Public Health in accordance with 42 CFR 485, Subpart
6 F. For outpatient services provided on or before June
7 30, 2018, the EAPG standardized amounts are determined
8 separately for each critical access hospital such that
9 simulated EAPG payments using outpatient base period
10 paid claim data plus payments under Section 5A-12.4 of
11 this Code net of the associated tax costs are equal to
12 the estimated costs of outpatient base period claims
13 data with a rate year cost inflation factor applied.
14 (3) In addition to the statewide-standardized amounts,
15 the Department shall develop adjusters to adjust the rate
16 of reimbursement for critical Medicaid hospital outpatient
17 providers or services, including outpatient high volume or
18 safety-net hospitals. Beginning July 1, 2018, the
19 outpatient high volume adjustor shall be increased to
20 increase annual expenditures associated with this adjustor
21 by $79,200,000, based on the State Fiscal Year 2015 base
22 year data and this adjustor shall apply to public
23 hospitals, except for large public hospitals, as defined
24 under 89 Ill. Adm. Code 148.25(a).
25 (4) Beginning July 1, 2018, in addition to the
26 statewide standardized amounts, the Department shall make
SB3365 Enrolled - 112 - LRB104 18483 SSS 31925 b
1 an add-on payment for outpatient expensive devices and
2 drugs. This add-on payment shall at least apply to claim
3 lines that: (i) are assigned with one of the following
4 EAPGs: 490, 1001 to 1020, and coded with one of the
5 following revenue codes: 0274 to 0276, 0278; or (ii) are
6 assigned with one of the following EAPGs: 430 to 441, 443,
7 444, 460 to 465, 495, 496, 1090. The add-on payment shall
8 be calculated as follows: the claim line's covered charges
9 multiplied by the hospital's total acute cost to charge
10 ratio, less the claim line's EAPG payment plus $1,000,
11 multiplied by 0.8.
12 (5) Beginning July 1, 2018, the statewide-standardized
13 amounts for outpatient services shall be increased by a
14 uniform percentage so that base claims projected
15 reimbursement is increased by an amount equal to no less
16 than the funds allocated in paragraph (1) of subsection
17 (b) of Section 5A-12.6, less the amount allocated under
18 paragraphs (8) and (9) of subsection (a) and paragraphs
19 (3) and (4) of this subsection multiplied by 46%.
20 (6) Effective for dates of service on or after July 1,
21 2018, the Department shall establish adjustments to the
22 statewide-standardized amounts for each Critical Access
23 Hospital, as designated by the Department of Public Health
24 in accordance with 42 CFR 485, Subpart F, such that each
25 Critical Access Hospital's standardized amount for
26 outpatient services shall be increased by the applicable
SB3365 Enrolled - 113 - LRB104 18483 SSS 31925 b
1 uniform percentage determined pursuant to paragraph (5) of
2 this subsection. It is the intent of the General Assembly
3 that the adjustments required under this paragraph (6) by
4 Public Act 100-1181 shall be applied retroactively to
5 claims for dates of service provided on or after July 1,
6 2018.
7 (7) Effective for dates of service on or after March
8 8, 2019 (the effective date of Public Act 100-1181), the
9 Department shall recalculate and implement an updated
10 statewide-standardized amount for outpatient services
11 provided by hospitals that are not Critical Access
12 Hospitals to reflect the applicable uniform percentage
13 determined pursuant to paragraph (5).
14 (1) Any recalculation to the
15 statewide-standardized amounts for outpatient services
16 provided by hospitals that are not Critical Access
17 Hospitals shall be the amount necessary to achieve the
18 increase in the statewide-standardized amounts for
19 outpatient services increased by a uniform percentage,
20 so that base claims projected reimbursement is
21 increased by an amount equal to no less than the funds
22 allocated in paragraph (1) of subsection (b) of
23 Section 5A-12.6, less the amount allocated under
24 paragraphs (8) and (9) of subsection (a) and
25 paragraphs (3) and (4) of this subsection, for all
26 hospitals that are not Critical Access Hospitals,
SB3365 Enrolled - 114 - LRB104 18483 SSS 31925 b
1 multiplied by 46%.
2 (2) It is the intent of the General Assembly that
3 the recalculations required under this paragraph (7)
4 by Public Act 100-1181 shall be applied prospectively
5 to claims for dates of service provided on or after
6 March 8, 2019 (the effective date of Public Act
7 100-1181) and that no recoupment or repayment by the
8 Department or an MCO of payments attributable to
9 recalculation under this paragraph (7), issued to the
10 hospital for dates of service on or after July 1, 2018
11 and before March 8, 2019 (the effective date of Public
12 Act 100-1181), shall be permitted.
13 (8) The Department shall ensure that all necessary
14 adjustments to the managed care organization capitation
15 base rates necessitated by the adjustments under
16 subparagraph (6) or (7) of this subsection are completed
17 and applied retroactively in accordance with Section
18 5-30.8 of this Code within 90 days of March 8, 2019 (the
19 effective date of Public Act 100-1181).
20 (9) Within 60 days after federal approval of the
21 change made to the assessment in Section 5A-2 by Public
22 Act 101-650, the Department shall incorporate into the
23 EAPG system for outpatient services those services
24 performed by hospitals currently billed through the
25 Non-Institutional Provider billing system.
26 (b-5) Notwithstanding any other provision of this Section,
SB3365 Enrolled - 115 - LRB104 18483 SSS 31925 b
1 beginning with dates of service on and after January 1, 2023,
2 any general acute care hospital with more than 500 outpatient
3 psychiatric Medicaid services to persons under 19 years of age
4 in any calendar year shall be paid the outpatient add-on
5 payment of no less than $113.
6 (c) In consultation with the hospital community, the
7 Department is authorized to replace 89 Ill. Adm. Code 152.150
8 as published in 38 Ill. Reg. 4980 through 4986 within 12 months
9 of June 16, 2014 (the effective date of Public Act 98-651). If
10 the Department does not replace these rules within 12 months
11 of June 16, 2014 (the effective date of Public Act 98-651), the
12 rules in effect for 152.150 as published in 38 Ill. Reg. 4980
13 through 4986 shall remain in effect until modified by rule by
14 the Department. Nothing in this subsection shall be construed
15 to mandate that the Department file a replacement rule.
16 (d) Transition period. There shall be a transition period
17 to the reimbursement systems authorized under this Section
18 that shall begin on the effective date of these systems and
19 continue until June 30, 2018, unless extended by rule by the
20 Department. To help provide an orderly and predictable
21 transition to the new reimbursement systems and to preserve
22 and enhance access to the hospital services during this
23 transition, the Department shall allocate a transitional
24 hospital access pool of at least $290,000,000 annually so that
25 transitional hospital access payments are made to hospitals.
26 (1) After the transition period, the Department may
SB3365 Enrolled - 116 - LRB104 18483 SSS 31925 b
1 begin incorporating the transitional hospital access pool
2 into the base rate structure; however, the transitional
3 hospital access payments in effect on June 30, 2018 shall
4 continue to be paid, if continued under Section 5A-16.
5 (2) After the transition period, if the Department
6 reduces payments from the transitional hospital access
7 pool, it shall increase base rates, develop new adjustors,
8 adjust current adjustors, develop new hospital access
9 payments based on updated information, or any combination
10 thereof by an amount equal to the decreases proposed in
11 the transitional hospital access pool payments, ensuring
12 that the entire transitional hospital access pool amount
13 shall continue to be used for hospital payments.
14 (d-5) Hospital and health care transformation program. The
15 Department shall develop a hospital and health care
16 transformation program to provide financial assistance to
17 hospitals in transforming their services and care models to
18 better align with the needs of the communities they serve. The
19 payments authorized in this Section shall be subject to
20 approval by the federal government.
21 (1) Phase 1. In State fiscal years 2019 through 2020,
22 the Department shall allocate funds from the transitional
23 access hospital pool to create a hospital transformation
24 pool of at least $262,906,870 annually and make hospital
25 transformation payments to hospitals. Subject to Section
26 5A-16, in State fiscal years 2019 and 2020, an Illinois
SB3365 Enrolled - 117 - LRB104 18483 SSS 31925 b
1 hospital that received either a transitional hospital
2 access payment under subsection (d) or a supplemental
3 payment under subsection (f) of this Section in State
4 fiscal year 2018, shall receive a hospital transformation
5 payment as follows:
6 (A) If the hospital's Rate Year 2017 Medicaid
7 inpatient utilization rate is equal to or greater than
8 45%, the hospital transformation payment shall be
9 equal to 100% of the sum of its transitional hospital
10 access payment authorized under subsection (d) and any
11 supplemental payment authorized under subsection (f).
12 (B) If the hospital's Rate Year 2017 Medicaid
13 inpatient utilization rate is equal to or greater than
14 25% but less than 45%, the hospital transformation
15 payment shall be equal to 75% of the sum of its
16 transitional hospital access payment authorized under
17 subsection (d) and any supplemental payment authorized
18 under subsection (f).
19 (C) If the hospital's Rate Year 2017 Medicaid
20 inpatient utilization rate is less than 25%, the
21 hospital transformation payment shall be equal to 50%
22 of the sum of its transitional hospital access payment
23 authorized under subsection (d) and any supplemental
24 payment authorized under subsection (f).
25 (2) Phase 2.
26 (A) The funding amount from phase one shall be
SB3365 Enrolled - 118 - LRB104 18483 SSS 31925 b
1 incorporated into directed payment and pass-through
2 payment methodologies described in Section 5A-12.7.
3 (B) Because there are communities in Illinois that
4 experience significant health care disparities due to
5 systemic racism, as recently emphasized by the
6 COVID-19 pandemic, aggravated by social determinants
7 of health and a lack of sufficiently allocated health
8 care resources, particularly community-based services,
9 preventive care, obstetric care, chronic disease
10 management, and specialty care, the Department shall
11 establish a health care transformation program that
12 shall be supported by the transformation funding pool.
13 It is the intention of the General Assembly that
14 innovative partnerships funded by the pool must be
15 designed to establish or improve integrated health
16 care delivery systems that will provide significant
17 access to the Medicaid and uninsured populations in
18 their communities, as well as improve health care
19 equity. It is also the intention of the General
20 Assembly that partnerships recognize and address the
21 disparities revealed by the COVID-19 pandemic, as well
22 as the need for post-COVID care. During State fiscal
23 years 2021 through 2027, the hospital and health care
24 transformation program shall be supported by an annual
25 transformation funding pool of up to $150,000,000,
26 pending federal matching funds, to be allocated during
SB3365 Enrolled - 119 - LRB104 18483 SSS 31925 b
1 the specified fiscal years for the purpose of
2 facilitating hospital and health care transformation.
3 Funds that had been budgeted but unexpended in State
4 fiscal years 2021 through 2027 may be allocated in
5 State fiscal year 2028 in an amount not to exceed
6 $150,000,000. No disbursement of moneys for
7 transformation projects from the transformation
8 funding pool described under this Section shall be
9 considered an award, a grant, or an expenditure of
10 grant funds. Funding agreements made in accordance
11 with the transformation program shall be considered
12 purchases of care under the Illinois Procurement Code,
13 and funds shall be expended by the Department in a
14 manner that maximizes federal funding to expend the
15 entire allocated amount.
16 The Department shall convene, within 30 days after
17 March 12, 2021 (the effective date of Public Act
18 101-655), a workgroup that includes subject matter
19 experts on health care disparities and stakeholders
20 from distressed communities, which could be a
21 subcommittee of the Medicaid Advisory Committee, to
22 review and provide recommendations on how Department
23 policy, including health care transformation, can
24 improve health disparities and the impact on
25 communities disproportionately affected by COVID-19.
26 The workgroup shall consider and make recommendations
SB3365 Enrolled - 120 - LRB104 18483 SSS 31925 b
1 on the following issues: a community safety-net
2 designation of certain hospitals, racial equity, and a
3 regional partnership to bring additional specialty
4 services to communities.
5 (C) As provided in paragraph (9) of Section 3 of
6 the Illinois Health Facilities Planning Act, any
7 hospital participating in the transformation program
8 may be excluded from the requirements of the Illinois
9 Health Facilities Planning Act for those projects
10 related to the hospital's transformation. To be
11 eligible, the hospital must submit to the Health
12 Facilities and Services Review Board approval from the
13 Department that the project is a part of the
14 hospital's transformation.
15 (D) As provided in subsection (a-20) of Section
16 32.5 of the Emergency Medical Services (EMS) Systems
17 Act, a hospital that received hospital transformation
18 payments under this Section may convert to a
19 freestanding emergency center. To be eligible for such
20 a conversion, the hospital must submit to the
21 Department of Public Health approval from the
22 Department that the project is a part of the
23 hospital's transformation.
24 (E) Criteria for proposals. To be eligible for
25 funding under this Section, a transformation proposal
26 shall meet all of the following criteria:
SB3365 Enrolled - 121 - LRB104 18483 SSS 31925 b
1 (i) the proposal shall be designed based on
2 community needs assessment completed by either a
3 University partner or other qualified entity with
4 significant community input;
5 (ii) the proposal shall be a collaboration
6 among providers across the care and community
7 spectrum, including preventative care, primary
8 care, specialty care, hospital services, mental
9 health and substance abuse services, as well as
10 community-based entities that address the social
11 determinants of health;
12 (iii) the proposal shall be specifically
13 designed to improve health care outcomes and
14 reduce health care disparities, and improve the
15 coordination, effectiveness, and efficiency of
16 care delivery;
17 (iv) the proposal shall have specific
18 measurable metrics related to disparities that
19 will be tracked by the Department and made public
20 by the Department;
21 (v) the proposal shall include a commitment to
22 include Business Enterprise Program certified
23 vendors or other entities controlled and managed
24 by minorities or women; and
25 (vi) the proposal shall specifically increase
26 access to primary, preventive, or specialty care.
SB3365 Enrolled - 122 - LRB104 18483 SSS 31925 b
1 (F) Entities eligible to be funded.
2 (i) Proposals for funding should come from
3 collaborations operating in one of the most
4 distressed communities in Illinois as determined
5 by the U.S. Centers for Disease Control and
6 Prevention's Social Vulnerability Index for
7 Illinois and areas disproportionately impacted by
8 COVID-19 or from rural areas of Illinois.
9 (ii) The Department shall prioritize
10 partnerships from distressed communities, which
11 include Business Enterprise Program certified
12 vendors or other entities controlled and managed
13 by minorities or women and also include one or
14 more of the following: safety-net hospitals,
15 critical access hospitals, the campuses of
16 hospitals that have closed since January 1, 2018,
17 or other health care providers designed to address
18 specific health care disparities, including the
19 impact of COVID-19 on individuals and the
20 community and the need for post-COVID care. All
21 funded proposals must include specific measurable
22 goals and metrics related to improved outcomes and
23 reduced disparities which shall be tracked by the
24 Department.
25 (iii) The Department should target the funding
26 in the following ways: $30,000,000 of
SB3365 Enrolled - 123 - LRB104 18483 SSS 31925 b
1 transformation funds to projects that are a
2 collaboration between a safety-net hospital,
3 particularly community safety-net hospitals, and
4 other providers and designed to address specific
5 health care disparities, $20,000,000 of
6 transformation funds to collaborations between
7 safety-net hospitals and a larger hospital partner
8 that increases specialty care in distressed
9 communities, $30,000,000 of transformation funds
10 to projects that are a collaboration between
11 hospitals and other providers in distressed areas
12 of the State designed to address specific health
13 care disparities, $15,000,000 to collaborations
14 between critical access hospitals and other
15 providers designed to address specific health care
16 disparities, and $15,000,000 to cross-provider
17 collaborations designed to address specific health
18 care disparities, and $5,000,000 to collaborations
19 that focus on workforce development.
20 (iv) The Department may allocate up to
21 $5,000,000 for planning, racial equity analysis,
22 or consulting resources for the Department or
23 entities without the resources to develop a plan
24 to meet the criteria of this Section. Any contract
25 for consulting services issued by the Department
26 under this subparagraph shall comply with the
SB3365 Enrolled - 124 - LRB104 18483 SSS 31925 b
1 provisions of Section 5-45 of the State Officials
2 and Employees Ethics Act. Based on availability of
3 federal funding, the Department may directly
4 procure consulting services or provide funding to
5 the collaboration. The provision of resources
6 under this subparagraph is not a guarantee that a
7 project will be approved.
8 (v) The Department shall take steps to ensure
9 that safety-net hospitals operating in
10 under-resourced communities receive priority
11 access to hospital and health care transformation
12 funds, including consulting funds, as provided
13 under this Section.
14 (G) Process for submitting and approving projects
15 for distressed communities. The Department shall issue
16 a template for application. The Department shall post
17 any proposal received on the Department's website for
18 at least 2 weeks for public comment, and any such
19 public comment shall also be considered in the review
20 process. Applicants may request that proprietary
21 financial information be redacted from publicly posted
22 proposals and the Department in its discretion may
23 agree. Proposals for each distressed community must
24 include all of the following:
25 (i) A detailed description of how the project
26 intends to affect the goals outlined in this
SB3365 Enrolled - 125 - LRB104 18483 SSS 31925 b
1 subsection, describing new interventions, new
2 technology, new structures, and other changes to
3 the health care delivery system planned.
4 (ii) A detailed description of the racial and
5 ethnic makeup of the entities' board and
6 leadership positions and the salaries of the
7 executive staff of entities in the partnership
8 that is seeking to obtain funding under this
9 Section.
10 (iii) A complete budget, including an overall
11 timeline and a detailed pathway to sustainability
12 within a 5-year period, specifying other sources
13 of funding, such as in-kind, cost-sharing, or
14 private donations, particularly for capital needs.
15 There is an expectation that parties to the
16 transformation project dedicate resources to the
17 extent they are able and that these expectations
18 are delineated separately for each entity in the
19 proposal.
20 (iv) A description of any new entities formed
21 or other legal relationships between collaborating
22 entities and how funds will be allocated among
23 participants.
24 (v) A timeline showing the evolution of sites
25 and specific services of the project over a 5-year
26 period, including services available to the
SB3365 Enrolled - 126 - LRB104 18483 SSS 31925 b
1 community by site.
2 (vi) Clear milestones indicating progress
3 toward the proposed goals of the proposal as
4 checkpoints along the way to continue receiving
5 funding. The Department is authorized to refine
6 these milestones in agreements, and is authorized
7 to impose reasonable penalties, including
8 repayment of funds, for substantial lack of
9 progress.
10 (vii) A clear statement of the level of
11 commitment the project will include for minorities
12 and women in contracting opportunities, including
13 as equity partners where applicable, or as
14 subcontractors and suppliers in all phases of the
15 project.
16 (viii) If the community study utilized is not
17 the study commissioned and published by the
18 Department, the applicant must define the
19 methodology used, including documentation of clear
20 community participation.
21 (ix) A description of the process used in
22 collaborating with all levels of government in the
23 community served in the development of the
24 project, including, but not limited to,
25 legislators and officials of other units of local
26 government.
SB3365 Enrolled - 127 - LRB104 18483 SSS 31925 b
1 (x) Documentation of a community input process
2 in the community served, including links to
3 proposal materials on public websites.
4 (xi) Verifiable project milestones and quality
5 metrics that will be impacted by transformation.
6 These project milestones and quality metrics must
7 be identified with improvement targets that must
8 be met.
9 (xii) Data on the number of existing employees
10 by various job categories and wage levels by the
11 zip code of the employees' residence and
12 benchmarks for the continued maintenance and
13 improvement of these levels. The proposal must
14 also describe any retraining or other workforce
15 development planned for the new project.
16 (xiii) If a new entity is created by the
17 project, a description of how the board will be
18 reflective of the community served by the
19 proposal.
20 (xiv) An explanation of how the proposal will
21 address the existing disparities that exacerbated
22 the impact of COVID-19 and the need for post-COVID
23 care in the community, if applicable.
24 (xv) An explanation of how the proposal is
25 designed to increase access to care, including
26 specialty care based upon the community's needs.
SB3365 Enrolled - 128 - LRB104 18483 SSS 31925 b
1 (H) The Department shall evaluate proposals for
2 compliance with the criteria listed under subparagraph
3 (G). Proposals meeting all of the criteria may be
4 eligible for funding with the areas of focus
5 prioritized as described in item (ii) of subparagraph
6 (F). Based on the funds available, the Department may
7 negotiate funding agreements with approved applicants
8 to maximize federal funding. Nothing in this
9 subsection requires that an approved project be funded
10 to the level requested. Agreements shall specify the
11 amount of funding anticipated annually, the
12 methodology of payments, the limit on the number of
13 years such funding may be provided, and the milestones
14 and quality metrics that must be met by the projects in
15 order to continue to receive funding during each year
16 of the program. Agreements shall specify the terms and
17 conditions under which a health care facility that
18 receives funds under a purchase of care agreement and
19 closes in violation of the terms of the agreement must
20 pay an early closure fee no greater than 50% of the
21 funds it received under the agreement, prior to the
22 Health Facilities and Services Review Board
23 considering an application for closure of the
24 facility. Any project that is funded shall be required
25 to provide quarterly written progress reports, in a
26 form prescribed by the Department, and at a minimum
SB3365 Enrolled - 129 - LRB104 18483 SSS 31925 b
1 shall include the progress made in achieving any
2 milestones or metrics or Business Enterprise Program
3 commitments in its plan. The Department may reduce or
4 end payments, as set forth in transformation plans, if
5 milestones or metrics or Business Enterprise Program
6 commitments are not achieved. The Department shall
7 seek to make payments from the transformation fund in
8 a manner that is eligible for federal matching funds.
9 In reviewing the proposals, the Department shall
10 take into account the needs of the community, data
11 from the study commissioned by the Department from the
12 University of Illinois-Chicago if applicable, feedback
13 from public comment on the Department's website, as
14 well as how the proposal meets the criteria listed
15 under subparagraph (G). Alignment with the
16 Department's overall strategic initiatives shall be an
17 important factor. To the extent that fiscal year
18 funding is not adequate to fund all eligible projects
19 that apply, the Department shall prioritize
20 applications that most comprehensively and effectively
21 address the criteria listed under subparagraph (G).
22 (3) (Blank).
23 (4) Hospital Transformation Review Committee. There is
24 created the Hospital Transformation Review Committee. The
25 Committee shall consist of 14 members. No later than 30
26 days after March 12, 2018 (the effective date of Public
SB3365 Enrolled - 130 - LRB104 18483 SSS 31925 b
1 Act 100-581), the 4 legislative leaders shall each appoint
2 3 members; the Governor shall appoint the Director of
3 Healthcare and Family Services, or his or her designee, as
4 a member; and the Director of Healthcare and Family
5 Services shall appoint one member. Any vacancy shall be
6 filled by the applicable appointing authority within 15
7 calendar days. The members of the Committee shall select a
8 Chair and a Vice-Chair from among its members, provided
9 that the Chair and Vice-Chair cannot be appointed by the
10 same appointing authority and must be from different
11 political parties. The Chair shall have the authority to
12 establish a meeting schedule and convene meetings of the
13 Committee, and the Vice-Chair shall have the authority to
14 convene meetings in the absence of the Chair. The
15 Committee may establish its own rules with respect to
16 meeting schedule, notice of meetings, and the disclosure
17 of documents; however, the Committee shall not have the
18 power to subpoena individuals or documents and any rules
19 must be approved by 9 of the 14 members. The Committee
20 shall perform the functions described in this Section and
21 advise and consult with the Director in the administration
22 of this Section. In addition to reviewing and approving
23 the policies, procedures, and rules for the hospital and
24 health care transformation program, the Committee shall
25 consider and make recommendations related to qualifying
26 criteria and payment methodologies related to safety-net
SB3365 Enrolled - 131 - LRB104 18483 SSS 31925 b
1 hospitals and children's hospitals. Members of the
2 Committee appointed by the legislative leaders shall be
3 subject to the jurisdiction of the Legislative Ethics
4 Commission, not the Executive Ethics Commission, and all
5 requests under the Freedom of Information Act shall be
6 directed to the applicable Freedom of Information officer
7 for the General Assembly. The Department shall provide
8 operational support to the Committee as necessary. The
9 Committee is dissolved on April 1, 2019.
10 (e) Beginning 36 months after initial implementation, the
11 Department shall update the reimbursement components in
12 subsections (a) and (b), including standardized amounts and
13 weighting factors, and at least once every 4 years and no more
14 frequently than annually thereafter. The Department shall
15 publish these updates on its website no later than 30 calendar
16 days prior to their effective date.
17 (f) Continuation of supplemental payments. Any
18 supplemental payments authorized under 89 Illinois
19 Administrative Code 148 effective January 1, 2014 and that
20 continue during the period of July 1, 2014 through December
21 31, 2014 shall remain in effect as long as the assessment
22 imposed by Section 5A-2 that is in effect on December 31, 2017
23 remains in effect.
24 (g) Notwithstanding subsections (a) through (f) of this
25 Section and notwithstanding the changes authorized under
26 Section 5-5b.1, any updates to the system shall not result in
SB3365 Enrolled - 132 - LRB104 18483 SSS 31925 b
1 any diminishment of the overall effective rates of
2 reimbursement as of the implementation date of the new system
3 (July 1, 2014). These updates shall not preclude variations in
4 any individual component of the system or hospital rate
5 variations. Nothing in this Section shall prohibit the
6 Department from increasing the rates of reimbursement or
7 developing payments to ensure access to hospital services.
8 Nothing in this Section shall be construed to guarantee a
9 minimum amount of spending in the aggregate or per hospital as
10 spending may be impacted by factors, including, but not
11 limited to, the number of individuals in the medical
12 assistance program and the severity of illness of the
13 individuals.
14 (h) The Department shall have the authority to modify by
15 rulemaking any changes to the rates or methodologies in this
16 Section as required by the federal government to obtain
17 federal financial participation for expenditures made under
18 this Section.
19 (i) Except for subsections (g) and (h) of this Section,
20 the Department shall, pursuant to subsection (c) of Section
21 5-40 of the Illinois Administrative Procedure Act, provide for
22 presentation at the June 2014 hearing of the Joint Committee
23 on Administrative Rules (JCAR) additional written notice to
24 JCAR of the following rules in order to commence the second
25 notice period for the following rules: rules published in the
26 Illinois Register, rule dated February 21, 2014 at 38 Ill.
SB3365 Enrolled - 133 - LRB104 18483 SSS 31925 b
1 Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
2 Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
3 Related Grouping (DRG) Prospective Payment System (PPS)), and
4 4977 (Hospital Reimbursement Changes), and published in the
5 Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
6 (Specialized Health Care Delivery Systems) and 6505 (Hospital
7 Services).
8 (j) Out-of-state hospitals. Beginning July 1, 2018, for
9 purposes of determining for State fiscal years 2019 and 2020
10 and subsequent fiscal years the hospitals eligible for the
11 payments authorized under subsections (a) and (b) of this
12 Section, the Department shall include out-of-state hospitals
13 that are designated a Level I pediatric trauma center or a
14 Level I trauma center by the Department of Public Health as of
15 December 1, 2017.
16 (k) The Department shall notify each hospital and managed
17 care organization, in writing, of the impact of the updates
18 under this Section at least 30 calendar days prior to their
19 effective date.
20 (k-5) The Department shall adopt amended rules, in advance
21 of the development of annual Calendar Year 2027 hospital
22 rates, to address the standardized process and time frame for
23 updates to the reimbursement components described in
24 subsections (a) and (b), including, but not limited to, the
25 definition of "excessive growth" in paragraph (4) of
26 subsection (a), in consultation with a statewide association
SB3365 Enrolled - 134 - LRB104 18483 SSS 31925 b
1 representing a majority of hospitals, to be undertaken prior
2 to initiating rulemaking in accordance with the Illinois
3 Administrative Procedure Act.
4 (l) This Section is subject to Section 14-12.5.
5 (Source: P.A. 103-102, eff. 6-16-23; 103-154, eff. 6-30-23;
6 104-9, eff. 6-16-25; 104-417, eff. 8-15-25.)
7 ARTICLE 30.
8 Section 30-5. The Illinois Public Aid Code is amended by
9 changing Section 12-9 as follows:
10 (305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
11 Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
12 Public Aid Recoveries Trust Fund shall consist of (1)
13 recoveries by the Department of Healthcare and Family Services
14 (formerly Illinois Department of Public Aid) authorized by
15 this Code in respect to applicants or recipients under
16 Articles III, IV, V, and VI, including recoveries made by the
17 Department of Healthcare and Family Services (formerly
18 Illinois Department of Public Aid) from the estates of
19 deceased recipients, (2) recoveries made by the Department of
20 Healthcare and Family Services (formerly Illinois Department
21 of Public Aid) in respect to applicants and recipients under
22 the Children's Health Insurance Program Act, and the Covering
23 ALL KIDS Health Insurance Act, (2.5) recoveries made by the
SB3365 Enrolled - 135 - LRB104 18483 SSS 31925 b
1 Department of Healthcare and Family Services in connection
2 with the imposition of an administrative penalty as provided
3 under Section 12-4.45, (3) federal funds received on behalf of
4 and earned by State universities, other State agencies or
5 departments, and local governmental entities for services
6 provided to applicants or recipients covered under this Code,
7 the Children's Health Insurance Program Act, and the Covering
8 ALL KIDS Health Insurance Act, (3.5) federal financial
9 participation revenue related to eligible disbursements made
10 by the Department of Healthcare and Family Services from
11 appropriations required by this Section, and (4) all other
12 moneys received to the Fund, including interest thereon. The
13 Fund shall be held as a special fund in the State Treasury.
14 Disbursements from this Fund shall be only (1) for the
15 reimbursement of claims collected by the Department of
16 Healthcare and Family Services (formerly Illinois Department
17 of Public Aid) through error or mistake, (2) for payment to
18 persons or agencies designated as payees or co-payees on any
19 instrument, whether or not negotiable, delivered to the
20 Department of Healthcare and Family Services (formerly
21 Illinois Department of Public Aid) as a recovery under this
22 Section, such payment to be in proportion to the respective
23 interests of the payees in the amount so collected, (3) for
24 payments to the Department of Human Services for collections
25 made by the Department of Healthcare and Family Services
26 (formerly Illinois Department of Public Aid) on behalf of the
SB3365 Enrolled - 136 - LRB104 18483 SSS 31925 b
1 Department of Human Services under this Code, the Children's
2 Health Insurance Program Act, and the Covering ALL KIDS Health
3 Insurance Act, (4) for payment of administrative expenses
4 incurred in performing the activities authorized under this
5 Code, the Children's Health Insurance Program Act, and the
6 Covering ALL KIDS Health Insurance Act, (5) for payment of
7 fees to persons or agencies in the performance of activities
8 pursuant to the collection of monies owed the State that are
9 collected under this Code, the Children's Health Insurance
10 Program Act, and the Covering ALL KIDS Health Insurance Act,
11 (6) separate from those disbursements allowed under items (4)
12 and (5), for payment of contingency fees to third-party
13 entities that the Office of Inspector General authorizes to
14 conduct audits under Sections 12-4.25 and 12-4.40, or any
15 similar audits required by State or federal law, (7) for
16 payments of any amounts which are reimbursable to the federal
17 government which are required to be paid by State warrant by
18 either the State or federal government, and (8) (7) for
19 payments to State universities, other State agencies or
20 departments, and local governmental entities of federal funds
21 for services provided to applicants or recipients covered
22 under this Code, the Children's Health Insurance Program Act,
23 and the Covering ALL KIDS Health Insurance Act. Disbursements
24 from this Fund for purposes of items (4) and (5) of this
25 paragraph shall be subject to appropriations from the Fund to
26 the Department of Healthcare and Family Services (formerly
SB3365 Enrolled - 137 - LRB104 18483 SSS 31925 b
1 Illinois Department of Public Aid).
2 The balance in this Fund after payment therefrom of any
3 amounts reimbursable to the federal government, and minus the
4 amount anticipated to be needed to make the disbursements
5 authorized by this Section, shall be certified by the Director
6 of Healthcare and Family Services and transferred by the State
7 Comptroller to the Drug Rebate Fund or the Healthcare Provider
8 Relief Fund in the State Treasury, as appropriate, on at least
9 an annual basis by June 30th of each fiscal year. The Director
10 of Healthcare and Family Services may certify and the State
11 Comptroller shall transfer to the Drug Rebate Fund or the
12 Healthcare Provider Relief Fund amounts on a more frequent
13 basis.
14 (Source: P.A. 103-593, eff. 6-7-24.)
15 ARTICLE 35.
16 Section 35-5. The Illinois Public Aid Code is amended by
17 changing Section 5-5.4 as follows:
18 (305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
19 Sec. 5-5.4. Standards of payment; Department of Healthcare
20 and Family Services. The Department of Healthcare and Family
21 Services shall develop standards of payment of nursing
22 facility and ICF/DD services in facilities providing such
23 services under this Article which:
SB3365 Enrolled - 138 - LRB104 18483 SSS 31925 b
1 (1) Provide for the determination of a facility's payment
2 for nursing facility or ICF/DD services on a prospective
3 basis. The amount of the payment rate for all nursing
4 facilities certified by the Department of Public Health under
5 the ID/DD Community Care Act or the Nursing Home Care Act as
6 Intermediate Care for the Developmentally Disabled facilities,
7 Long Term Care for Under Age 22 facilities, Skilled Nursing
8 facilities, or Intermediate Care facilities under the medical
9 assistance program shall be prospectively established annually
10 on the basis of historical, financial, and statistical data
11 reflecting actual costs from prior years, which shall be
12 applied to the current rate year and updated for inflation,
13 except that the capital cost element for newly constructed
14 facilities shall be based upon projected budgets. The annually
15 established payment rate shall take effect on July 1 in 1984
16 and subsequent years. No rate increase and no update for
17 inflation shall be provided on or after July 1, 1994, unless
18 specifically provided for in this Section. The changes made by
19 Public Act 93-841 extending the duration of the prohibition
20 against a rate increase or update for inflation are effective
21 retroactive to July 1, 2004.
22 For facilities licensed by the Department of Public Health
23 under the Nursing Home Care Act as Intermediate Care for the
24 Developmentally Disabled facilities or Long Term Care for
25 Under Age 22 facilities, the rates taking effect on July 1,
26 1998 shall include an increase of 3%. For facilities licensed
SB3365 Enrolled - 139 - LRB104 18483 SSS 31925 b
1 by the Department of Public Health under the Nursing Home Care
2 Act as Skilled Nursing facilities or Intermediate Care
3 facilities, the rates taking effect on July 1, 1998 shall
4 include an increase of 3% plus $1.10 per resident-day, as
5 defined by the Department. For facilities licensed by the
6 Department of Public Health under the Nursing Home Care Act as
7 Intermediate Care Facilities for the Developmentally Disabled
8 or Long Term Care for Under Age 22 facilities, the rates taking
9 effect on January 1, 2006 shall include an increase of 3%. For
10 facilities licensed by the Department of Public Health under
11 the Nursing Home Care Act as Intermediate Care Facilities for
12 the Developmentally Disabled or Long Term Care for Under Age
13 22 facilities, the rates taking effect on January 1, 2009
14 shall include an increase sufficient to provide a $0.50 per
15 hour wage increase for non-executive staff. For facilities
16 licensed by the Department of Public Health under the ID/DD
17 Community Care Act as ID/DD Facilities the rates taking effect
18 within 30 days after July 6, 2017 (the effective date of Public
19 Act 100-23) shall include an increase sufficient to provide a
20 $0.75 per hour wage increase for non-executive staff. The
21 Department shall adopt rules, including emergency rules under
22 subsection (y) of Section 5-45 of the Illinois Administrative
23 Procedure Act, to implement the provisions of this paragraph.
24 For facilities licensed by the Department of Public Health
25 under the ID/DD Community Care Act as ID/DD Facilities and
26 under the MC/DD Act as MC/DD Facilities, the rates taking
SB3365 Enrolled - 140 - LRB104 18483 SSS 31925 b
1 effect within 30 days after June 5, 2019 (the effective date of
2 Public Act 101-10) shall include an increase sufficient to
3 provide a $0.50 per hour wage increase for non-executive
4 frontline personnel, including, but not limited to, direct
5 support persons, aides, frontline supervisors, qualified
6 intellectual disabilities professionals, nurses, and
7 non-administrative support staff. The Department shall adopt
8 rules, including emergency rules under subsection (bb) of
9 Section 5-45 of the Illinois Administrative Procedure Act, to
10 implement the provisions of this paragraph.
11 For facilities licensed by the Department of Public Health
12 under the Nursing Home Care Act as Intermediate Care for the
13 Developmentally Disabled facilities or Long Term Care for
14 Under Age 22 facilities, the rates taking effect on July 1,
15 1999 shall include an increase of 1.6% plus $3.00 per
16 resident-day, as defined by the Department. For facilities
17 licensed by the Department of Public Health under the Nursing
18 Home Care Act as Skilled Nursing facilities or Intermediate
19 Care facilities, the rates taking effect on July 1, 1999 shall
20 include an increase of 1.6% and, for services provided on or
21 after October 1, 1999, shall be increased by $4.00 per
22 resident-day, as defined by the Department.
23 For facilities licensed by the Department of Public Health
24 under the Nursing Home Care Act as Intermediate Care for the
25 Developmentally Disabled facilities or Long Term Care for
26 Under Age 22 facilities, the rates taking effect on July 1,
SB3365 Enrolled - 141 - LRB104 18483 SSS 31925 b
1 2000 shall include an increase of 2.5% per resident-day, as
2 defined by the Department. For facilities licensed by the
3 Department of Public Health under the Nursing Home Care Act as
4 Skilled Nursing facilities or Intermediate Care facilities,
5 the rates taking effect on July 1, 2000 shall include an
6 increase of 2.5% per resident-day, as defined by the
7 Department.
8 For facilities licensed by the Department of Public Health
9 under the Nursing Home Care Act as skilled nursing facilities
10 or intermediate care facilities, a new payment methodology
11 must be implemented for the nursing component of the rate
12 effective July 1, 2003. The Department of Public Aid (now
13 Healthcare and Family Services) shall develop the new payment
14 methodology using the Minimum Data Set (MDS) as the instrument
15 to collect information concerning nursing home resident
16 condition necessary to compute the rate. The Department shall
17 develop the new payment methodology to meet the unique needs
18 of Illinois nursing home residents while remaining subject to
19 the appropriations provided by the General Assembly. A
20 transition period from the payment methodology in effect on
21 June 30, 2003 to the payment methodology in effect on July 1,
22 2003 shall be provided for a period not exceeding 3 years and
23 184 days after implementation of the new payment methodology
24 as follows:
25 (A) For a facility that would receive a lower nursing
26 component rate per patient day under the new system than
SB3365 Enrolled - 142 - LRB104 18483 SSS 31925 b
1 the facility received effective on the date immediately
2 preceding the date that the Department implements the new
3 payment methodology, the nursing component rate per
4 patient day for the facility shall be held at the level in
5 effect on the date immediately preceding the date that the
6 Department implements the new payment methodology until a
7 higher nursing component rate of reimbursement is achieved
8 by that facility.
9 (B) For a facility that would receive a higher nursing
10 component rate per patient day under the payment
11 methodology in effect on July 1, 2003 than the facility
12 received effective on the date immediately preceding the
13 date that the Department implements the new payment
14 methodology, the nursing component rate per patient day
15 for the facility shall be adjusted.
16 (C) Notwithstanding paragraphs (A) and (B), the
17 nursing component rate per patient day for the facility
18 shall be adjusted subject to appropriations provided by
19 the General Assembly.
20 For facilities licensed by the Department of Public Health
21 under the Nursing Home Care Act as Intermediate Care for the
22 Developmentally Disabled facilities or Long Term Care for
23 Under Age 22 facilities, the rates taking effect on March 1,
24 2001 shall include a statewide increase of 7.85%, as defined
25 by the Department.
26 Notwithstanding any other provision of this Section, for
SB3365 Enrolled - 143 - LRB104 18483 SSS 31925 b
1 facilities licensed by the Department of Public Health under
2 the Nursing Home Care Act as skilled nursing facilities or
3 intermediate care facilities, except facilities participating
4 in the Department's demonstration program pursuant to the
5 provisions of Title 77, Part 300, Subpart T of the Illinois
6 Administrative Code, the numerator of the ratio used by the
7 Department of Healthcare and Family Services to compute the
8 rate payable under this Section using the Minimum Data Set
9 (MDS) methodology shall incorporate the following annual
10 amounts as the additional funds appropriated to the Department
11 specifically to pay for rates based on the MDS nursing
12 component methodology in excess of the funding in effect on
13 December 31, 2006:
14 (i) For rates taking effect January 1, 2007,
15 $60,000,000.
16 (ii) For rates taking effect January 1, 2008,
17 $110,000,000.
18 (iii) For rates taking effect January 1, 2009,
19 $194,000,000.
20 (iv) For rates taking effect April 1, 2011, or the
21 first day of the month that begins at least 45 days after
22 February 16, 2011 (the effective date of Public Act
23 96-1530), $416,500,000 or an amount as may be necessary to
24 complete the transition to the MDS methodology for the
25 nursing component of the rate. Increased payments under
26 this item (iv) are not due and payable, however, until (i)
SB3365 Enrolled - 144 - LRB104 18483 SSS 31925 b
1 the methodologies described in this paragraph are approved
2 by the federal government in an appropriate State Plan
3 amendment and (ii) the assessment imposed by Section 5B-2
4 of this Code is determined to be a permissible tax under
5 Title XIX of the Social Security Act.
6 Notwithstanding any other provision of this Section, for
7 facilities licensed by the Department of Public Health under
8 the Nursing Home Care Act as skilled nursing facilities or
9 intermediate care facilities, the support component of the
10 rates taking effect on January 1, 2008 shall be computed using
11 the most recent cost reports on file with the Department of
12 Healthcare and Family Services no later than April 1, 2005,
13 updated for inflation to January 1, 2006.
14 For facilities licensed by the Department of Public Health
15 under the Nursing Home Care Act as Intermediate Care for the
16 Developmentally Disabled facilities or Long Term Care for
17 Under Age 22 facilities, the rates taking effect on April 1,
18 2002 shall include a statewide increase of 2.0%, as defined by
19 the Department. This increase terminates on July 1, 2002;
20 beginning July 1, 2002 these rates are reduced to the level of
21 the rates in effect on March 31, 2002, as defined by the
22 Department.
23 For facilities licensed by the Department of Public Health
24 under the Nursing Home Care Act as skilled nursing facilities
25 or intermediate care facilities, the rates taking effect on
26 July 1, 2001 shall be computed using the most recent cost
SB3365 Enrolled - 145 - LRB104 18483 SSS 31925 b
1 reports on file with the Department of Public Aid no later than
2 April 1, 2000, updated for inflation to January 1, 2001. For
3 rates effective July 1, 2001 only, rates shall be the greater
4 of the rate computed for July 1, 2001 or the rate effective on
5 June 30, 2001.
6 Notwithstanding any other provision of this Section, for
7 facilities licensed by the Department of Public Health under
8 the Nursing Home Care Act as skilled nursing facilities or
9 intermediate care facilities, the Illinois Department shall
10 determine by rule the rates taking effect on July 1, 2002,
11 which shall be 5.9% less than the rates in effect on June 30,
12 2002.
13 Notwithstanding any other provision of this Section, for
14 facilities licensed by the Department of Public Health under
15 the Nursing Home Care Act as skilled nursing facilities or
16 intermediate care facilities, if the payment methodologies
17 required under Section 5A-12 and the waiver granted under 42
18 CFR 433.68 are approved by the United States Centers for
19 Medicare and Medicaid Services, the rates taking effect on
20 July 1, 2004 shall be 3.0% greater than the rates in effect on
21 June 30, 2004. These rates shall take effect only upon
22 approval and implementation of the payment methodologies
23 required under Section 5A-12.
24 Notwithstanding any other provisions of this Section, for
25 facilities licensed by the Department of Public Health under
26 the Nursing Home Care Act as skilled nursing facilities or
SB3365 Enrolled - 146 - LRB104 18483 SSS 31925 b
1 intermediate care facilities, the rates taking effect on
2 January 1, 2005 shall be 3% more than the rates in effect on
3 December 31, 2004.
4 Notwithstanding any other provision of this Section, for
5 facilities licensed by the Department of Public Health under
6 the Nursing Home Care Act as skilled nursing facilities or
7 intermediate care facilities, effective January 1, 2009, the
8 per diem support component of the rates effective on January
9 1, 2008, computed using the most recent cost reports on file
10 with the Department of Healthcare and Family Services no later
11 than April 1, 2005, updated for inflation to January 1, 2006,
12 shall be increased to the amount that would have been derived
13 using standard Department of Healthcare and Family Services
14 methods, procedures, and inflators.
15 Notwithstanding any other provisions of this Section, for
16 facilities licensed by the Department of Public Health under
17 the Nursing Home Care Act as intermediate care facilities that
18 are federally defined as Institutions for Mental Disease, or
19 facilities licensed by the Department of Public Health under
20 the Specialized Mental Health Rehabilitation Act of 2013, a
21 socio-development component rate equal to 6.6% of the
22 facility's nursing component rate as of January 1, 2006 shall
23 be established and paid effective July 1, 2006. The
24 socio-development component of the rate shall be increased by
25 a factor of 2.53 on the first day of the month that begins at
26 least 45 days after January 11, 2008 (the effective date of
SB3365 Enrolled - 147 - LRB104 18483 SSS 31925 b
1 Public Act 95-707). As of August 1, 2008, the
2 socio-development component rate shall be equal to 6.6% of the
3 facility's nursing component rate as of January 1, 2006,
4 multiplied by a factor of 3.53. For services provided on or
5 after April 1, 2011, or the first day of the month that begins
6 at least 45 days after February 16, 2011 (the effective date of
7 Public Act 96-1530), whichever is later, the Illinois
8 Department may by rule adjust these socio-development
9 component rates, and may use different adjustment
10 methodologies for those facilities participating, and those
11 not participating, in the Illinois Department's demonstration
12 program pursuant to the provisions of Title 77, Part 300,
13 Subpart T of the Illinois Administrative Code, but in no case
14 may such rates be diminished below those in effect on August 1,
15 2008.
16 For facilities licensed by the Department of Public Health
17 under the Nursing Home Care Act as Intermediate Care for the
18 Developmentally Disabled facilities or as long-term care
19 facilities for residents under 22 years of age, the rates
20 taking effect on July 1, 2003 shall include a statewide
21 increase of 4%, as defined by the Department.
22 For facilities licensed by the Department of Public Health
23 under the Nursing Home Care Act as Intermediate Care for the
24 Developmentally Disabled facilities or Long Term Care for
25 Under Age 22 facilities, the rates taking effect on the first
26 day of the month that begins at least 45 days after January 11,
SB3365 Enrolled - 148 - LRB104 18483 SSS 31925 b
1 2008 (the effective date of Public Act 95-707) shall include a
2 statewide increase of 2.5%, as defined by the Department.
3 Notwithstanding any other provision of this Section, for
4 facilities licensed by the Department of Public Health under
5 the Nursing Home Care Act as skilled nursing facilities or
6 intermediate care facilities, effective January 1, 2005,
7 facility rates shall be increased by the difference between
8 (i) a facility's per diem property, liability, and malpractice
9 insurance costs as reported in the cost report filed with the
10 Department of Public Aid and used to establish rates effective
11 July 1, 2001 and (ii) those same costs as reported in the
12 facility's 2002 cost report. These costs shall be passed
13 through to the facility without caps or limitations, except
14 for adjustments required under normal auditing procedures.
15 Rates established effective each July 1 shall govern
16 payment for services rendered throughout that fiscal year,
17 except that rates established on July 1, 1996 shall be
18 increased by 6.8% for services provided on or after January 1,
19 1997. Such rates will be based upon the rates calculated for
20 the year beginning July 1, 1990, and for subsequent years
21 thereafter until June 30, 2001 shall be based on the facility
22 cost reports for the facility fiscal year ending at any point
23 in time during the previous calendar year, updated to the
24 midpoint of the rate year. The cost report shall be on file
25 with the Department no later than April 1 of the current rate
26 year. Should the cost report not be on file by April 1, the
SB3365 Enrolled - 149 - LRB104 18483 SSS 31925 b
1 Department shall base the rate on the latest cost report filed
2 by each skilled care facility and intermediate care facility,
3 updated to the midpoint of the current rate year. In
4 determining rates for services rendered on and after July 1,
5 1985, fixed time shall not be computed at less than zero. The
6 Department shall not make any alterations of regulations which
7 would reduce any component of the Medicaid rate to a level
8 below what that component would have been utilizing in the
9 rate effective on July 1, 1984.
10 (2) Shall take into account the actual costs incurred by
11 facilities in providing services for recipients of skilled
12 nursing and intermediate care services under the medical
13 assistance program.
14 (3) Shall take into account the medical and psycho-social
15 characteristics and needs of the patients.
16 (4) Shall take into account the actual costs incurred by
17 facilities in meeting licensing and certification standards
18 imposed and prescribed by the State of Illinois, any of its
19 political subdivisions or municipalities and by the U.S.
20 Department of Health and Human Services pursuant to Title XIX
21 of the Social Security Act.
22 The Department of Healthcare and Family Services shall
23 develop precise standards for payments to reimburse nursing
24 facilities for any utilization of appropriate rehabilitative
25 personnel for the provision of rehabilitative services which
26 is authorized by federal regulations, including reimbursement
SB3365 Enrolled - 150 - LRB104 18483 SSS 31925 b
1 for services provided by qualified therapists or qualified
2 assistants, and which is in accordance with accepted
3 professional practices. Reimbursement also may be made for
4 utilization of other supportive personnel under appropriate
5 supervision.
6 The Department shall develop enhanced payments to offset
7 the additional costs incurred by a facility serving
8 exceptional need residents and shall allocate at least
9 $4,000,000 of the funds collected from the assessment
10 established by Section 5B-2 of this Code for such payments.
11 For the purpose of this Section, "exceptional needs" means,
12 but need not be limited to, ventilator care and traumatic
13 brain injury care. The enhanced payments for exceptional need
14 residents under this paragraph are not due and payable,
15 however, until (i) the methodologies described in this
16 paragraph are approved by the federal government in an
17 appropriate State Plan amendment and (ii) the assessment
18 imposed by Section 5B-2 of this Code is determined to be a
19 permissible tax under Title XIX of the Social Security Act.
20 Beginning January 1, 2014 the methodologies for
21 reimbursement of nursing facility services as provided under
22 this Section 5-5.4 shall no longer be applicable for services
23 provided on or after January 1, 2014.
24 No payment increase under this Section for the MDS
25 methodology, exceptional care residents, or the
26 socio-development component rate established by Public Act
SB3365 Enrolled - 151 - LRB104 18483 SSS 31925 b
1 96-1530 of the 96th General Assembly and funded by the
2 assessment imposed under Section 5B-2 of this Code shall be
3 due and payable until after the Department notifies the
4 long-term care providers, in writing, that the payment
5 methodologies to long-term care providers required under this
6 Section have been approved by the Centers for Medicare and
7 Medicaid Services of the U.S. Department of Health and Human
8 Services and the waivers under 42 CFR 433.68 for the
9 assessment imposed by this Section, if necessary, have been
10 granted by the Centers for Medicare and Medicaid Services of
11 the U.S. Department of Health and Human Services. Upon
12 notification to the Department of approval of the payment
13 methodologies required under this Section and the waivers
14 granted under 42 CFR 433.68, all increased payments otherwise
15 due under this Section prior to the date of notification shall
16 be due and payable within 90 days of the date federal approval
17 is received.
18 On and after July 1, 2012, the Department shall reduce any
19 rate of reimbursement for services or other payments or alter
20 any methodologies authorized by this Code to reduce any rate
21 of reimbursement for services or other payments in accordance
22 with Section 5-5e.
23 For facilities licensed by the Department of Public Health
24 under the ID/DD Community Care Act as ID/DD Facilities and
25 under the MC/DD Act as MC/DD Facilities, subject to federal
26 approval, the rates taking effect for services delivered on or
SB3365 Enrolled - 152 - LRB104 18483 SSS 31925 b
1 after August 1, 2019 shall be increased by 3.5% over the rates
2 in effect on June 30, 2019. The Department shall adopt rules,
3 including emergency rules under subsection (ii) of Section
4 5-45 of the Illinois Administrative Procedure Act, to
5 implement the provisions of this Section, including wage
6 increases for direct care staff.
7 For facilities licensed by the Department of Public Health
8 under the ID/DD Community Care Act as ID/DD Facilities and
9 under the MC/DD Act as MC/DD Facilities, subject to federal
10 approval, the rates taking effect on the latter of the
11 approval date of the State Plan Amendment for these facilities
12 or the Waiver Amendment for the home and community-based
13 services settings shall include an increase sufficient to
14 provide a $0.26 per hour wage increase to the base wage for
15 non-executive staff. The Department shall adopt rules,
16 including emergency rules as authorized by Section 5-45 of the
17 Illinois Administrative Procedure Act, to implement the
18 provisions of this Section, including wage increases for
19 direct care staff.
20 For facilities licensed by the Department of Public Health
21 under the ID/DD Community Care Act as ID/DD Facilities and
22 under the MC/DD Act as MC/DD Facilities, subject to federal
23 approval of the State Plan Amendment and the Waiver Amendment
24 for the home and community-based services settings, the rates
25 taking effect for the services delivered on or after July 1,
26 2020 shall include an increase sufficient to provide a $1.00
SB3365 Enrolled - 153 - LRB104 18483 SSS 31925 b
1 per hour wage increase for non-executive staff. For services
2 delivered on or after January 1, 2021, subject to federal
3 approval of the State Plan Amendment and the Waiver Amendment
4 for the home and community-based services settings, shall
5 include an increase sufficient to provide a $0.50 per hour
6 increase for non-executive staff. The Department shall adopt
7 rules, including emergency rules as authorized by Section 5-45
8 of the Illinois Administrative Procedure Act, to implement the
9 provisions of this Section, including wage increases for
10 direct care staff.
11 For facilities licensed by the Department of Public Health
12 under the ID/DD Community Care Act as ID/DD Facilities and
13 under the MC/DD Act as MC/DD Facilities, subject to federal
14 approval of the State Plan Amendment, the rates taking effect
15 for the residential services delivered on or after July 1,
16 2021, shall include an increase sufficient to provide a $0.50
17 per hour increase for aides in the rate methodology. For
18 facilities licensed by the Department of Public Health under
19 the ID/DD Community Care Act as ID/DD Facilities and under the
20 MC/DD Act as MC/DD Facilities, subject to federal approval of
21 the State Plan Amendment, the rates taking effect for the
22 residential services delivered on or after January 1, 2022
23 shall include an increase sufficient to provide a $1.00 per
24 hour increase for aides in the rate methodology. In addition,
25 for residential services delivered on or after January 1, 2022
26 such rates shall include an increase sufficient to provide
SB3365 Enrolled - 154 - LRB104 18483 SSS 31925 b
1 wages for all residential non-executive direct care staff,
2 excluding aides, at the federal Department of Labor, Bureau of
3 Labor Statistics' average wage as defined in rule by the
4 Department. The Department shall adopt rules, including
5 emergency rules as authorized by Section 5-45 of the Illinois
6 Administrative Procedure Act, to implement the provisions of
7 this Section.
8 For facilities licensed by the Department of Public Health
9 under the ID/DD Community Care Act as ID/DD facilities and
10 under the MC/DD Act as MC/DD facilities, subject to federal
11 approval of the State Plan Amendment, the rates taking effect
12 for services delivered on or after January 1, 2023, shall
13 include a $1.00 per hour wage increase for all direct support
14 personnel and all other frontline personnel who are not
15 subject to the Bureau of Labor Statistics' average wage
16 increases, who work in residential and community day services
17 settings, with at least $0.50 of those funds to be provided as
18 a direct increase to all aide base wages, with the remaining
19 $0.50 to be used flexibly for base wage increases to the rate
20 methodology for aides. In addition, for residential services
21 delivered on or after January 1, 2023 the rates shall include
22 an increase sufficient to provide wages for all residential
23 non-executive direct care staff, excluding aides, at the
24 federal Department of Labor, Bureau of Labor Statistics'
25 average wage as determined by the Department. Also, for
26 services delivered on or after January 1, 2023, the rates will
SB3365 Enrolled - 155 - LRB104 18483 SSS 31925 b
1 include adjustments to employment-related expenses as defined
2 in rule by the Department. The Department shall adopt rules,
3 including emergency rules as authorized by Section 5-45 of the
4 Illinois Administrative Procedure Act, to implement the
5 provisions of this Section.
6 For facilities licensed by the Department of Public Health
7 under the ID/DD Community Care Act as ID/DD facilities and
8 under the MC/DD Act as MC/DD facilities, subject to federal
9 approval of the State Plan Amendment, the rates taking effect
10 for services delivered on or after January 1, 2024 shall
11 include a $2.50 per hour wage increase for all direct support
12 personnel and all other frontline personnel who are not
13 subject to the Bureau of Labor Statistics' average wage
14 increases and who work in residential and community day
15 services settings. At least $1.25 of the per hour wage
16 increase shall be provided as a direct increase to all aide
17 base wages, and the remaining $1.25 of the per hour wage
18 increase shall be used flexibly for base wage increases to the
19 rate methodology for aides. In addition, for residential
20 services delivered on or after January 1, 2024, the rates
21 shall include an increase sufficient to provide wages for all
22 residential non-executive direct care staff, excluding aides,
23 at the federal Department of Labor, Bureau of Labor
24 Statistics' average wage as determined by the Department.
25 Also, for services delivered on or after January 1, 2024, the
26 rates will include adjustments to employment-related expenses
SB3365 Enrolled - 156 - LRB104 18483 SSS 31925 b
1 as defined in rule by the Department. The Department shall
2 adopt rules, including emergency rules as authorized by
3 Section 5-45 of the Illinois Administrative Procedure Act, to
4 implement the provisions of this Section.
5 For facilities licensed by the Department of Public Health
6 under the ID/DD Community Care Act as ID/DD facilities and
7 under the MC/DD Act as MC/DD facilities, subject to federal
8 approval of a State Plan Amendment, the rates taking effect
9 for services delivered on or after January 1, 2025 shall
10 include a $1.00 per hour wage increase for all direct support
11 personnel and all other frontline personnel who are not
12 subject to the Bureau of Labor Statistics' average wage
13 increases and who work in residential and community day
14 services settings, with at least $0.75 of those funds to be
15 provided as a direct increase to all aide base wages and the
16 remaining $0.25 to be used flexibly for base wage increases to
17 the rate methodology for aides. These increases shall not be
18 used by facilities for operational and administrative
19 expenses. In addition, for residential services delivered on
20 or after January 1, 2025, the rates shall include an increase
21 sufficient to provide wages for all residential non-executive
22 direct care staff, excluding aides, at the federal Department
23 of Labor, Bureau of Labor Statistics' average wage as
24 determined by the Department. Also, for services delivered on
25 or after January 1, 2025, the rates will include adjustments
26 to employment-related expenses as defined in rule by the
SB3365 Enrolled - 157 - LRB104 18483 SSS 31925 b
1 Department. The Department shall adopt rules, including
2 emergency rules as authorized by Section 5-45 of the Illinois
3 Administrative Procedure Act, to implement the provisions of
4 this Section.
5 For facilities licensed by the Department of Public Health
6 under the ID/DD Community Care Act as ID/DD facilities and
7 under the MC/DD Act as MC/DD facilities, subject to federal
8 approval of a State Plan Amendment, the rates taking effect
9 for services delivered on or after January 1, 2026 shall
10 include a $0.80 per hour wage increase for all direct support
11 personnel and all other frontline personnel who are not
12 subject to the Bureau of Labor Statistics' average wage
13 increases and who work in residential and community day
14 services settings, with at least $0.60 of those funds to be
15 provided as a direct increase to all aide base wages and the
16 remaining $0.20 to be used flexibly for base wage increases to
17 the rate methodology for aides. These increases shall not be
18 used by facilities for operational and administrative
19 expenses. In addition, for residential services delivered on
20 or after January 1, 2026, the rates shall include an increase
21 sufficient to provide wages for all residential non-executive
22 direct care staff, excluding aides, at the federal Department
23 of Labor, Bureau of Labor Statistics' average wage as
24 determined by the Department. Also, for services delivered on
25 or after January 1, 2026, the rates will include adjustments
26 to employment-related expenses as defined in rule by the
SB3365 Enrolled - 158 - LRB104 18483 SSS 31925 b
1 Department. The Department shall adopt rules, including
2 emergency rules as authorized by Section 5-45 of the Illinois
3 Administrative Procedure Act, to implement the provisions of
4 this Section.
5 Notwithstanding any other provision of this Section to the
6 contrary, any regional wage adjuster for facilities located
7 outside of the counties of Cook, DuPage, Kane, Lake, McHenry,
8 and Will shall be no lower than 1.00, and any regional wage
9 adjuster for facilities located within the counties of Cook,
10 DuPage, Kane, Lake, McHenry, and Will shall be no lower than
11 1.15.
12 (5) For dates of service starting July 1, 2027,
13 reimbursement calculations and direct payments for services
14 provided by facilities licensed under the ID/DD Community Care
15 Act are the responsibility of the Department of Healthcare and
16 Family Services. Appropriations for facilities licensed under
17 the ID/DD Community Care Act must be shifted from the
18 Department of Human Services to the Department of Healthcare
19 and Family Services. Nothing in this Section shall prohibit
20 the Department of Healthcare and Family Services from paying
21 more than the rates specified in this Section. Nothing in this
22 Section shall affect the requirements of Section 3-213 of the
23 ID/DD Community Care Act.
24 (Source: P.A. 103-8, eff. 6-7-23; 103-588, eff. 7-1-24; 104-2,
25 eff. 6-16-25.)
SB3365 Enrolled - 159 - LRB104 18483 SSS 31925 b
1 ARTICLE 40.
2 Section 40-5. The Illinois Public Aid Code is amended by
3 changing Section 5-5e.1 as follows:
4 (305 ILCS 5/5-5e.1)
5 Sec. 5-5e.1. Safety-Net Hospitals.
6 (a) A Safety-Net Hospital is an Illinois hospital that:
7 (1) is licensed by the Department of Public Health as
8 a general acute care or pediatric hospital; and
9 (2) is a disproportionate share hospital, as described
10 in Section 1923 of the federal Social Security Act, as
11 determined by the Department; and
12 (3) meets one of the following:
13 (A) has a MIUR of at least 40% and a charity
14 percent of at least 4%; or
15 (B) has a MIUR of at least 50%.
16 (b) Definitions. As used in this Section:
17 (1) "Charity percent" means the ratio of (i) the
18 hospital's charity charges for services provided to
19 individuals without health insurance or another source of
20 third party coverage to (ii) the Illinois total hospital
21 charges, each as reported on the hospital's OBRA form.
22 (2) "MIUR" means Medicaid Inpatient Utilization Rate
23 and is defined as a fraction, the numerator of which is the
24 number of a hospital's inpatient days provided in the
SB3365 Enrolled - 160 - LRB104 18483 SSS 31925 b
1 hospital's fiscal year ending 3 years prior to the rate
2 year, to patients who, for such days, were eligible for
3 Medicaid under Title XIX of the federal Social Security
4 Act, 42 USC 1396a et seq., excluding those persons
5 eligible for medical assistance pursuant to 42 U.S.C.
6 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
7 Section 5-2 of this Article, and the denominator of which
8 is the total number of the hospital's inpatient days in
9 that same period, excluding those persons eligible for
10 medical assistance pursuant to 42 U.S.C.
11 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
12 Section 5-2 of this Article.
13 (3) "OBRA form" means form HFS-3834, OBRA '93 data
14 collection form, for the rate year.
15 (4) "Rate year" means the 12-month period beginning on
16 October 1.
17 (c) Beginning July 1, 2012 and ending on December 31, 2028
18 2026, a hospital that would have qualified for the rate year
19 beginning October 1, 2011 or October 1, 2012 shall be a
20 Safety-Net Hospital.
21 (c-5) Beginning July 1, 2020 and ending on December 31,
22 2026, a hospital that would have qualified for the rate year
23 beginning October 1, 2020 and was designated a federal rural
24 referral center under 42 CFR 412.96 as of October 1, 2020 shall
25 be a Safety-Net Hospital.
26 (d) No later than August 15 preceding the rate year, each
SB3365 Enrolled - 161 - LRB104 18483 SSS 31925 b
1 hospital shall submit the OBRA form to the Department. Prior
2 to October 1, the Department shall notify each hospital
3 whether it has qualified as a Safety-Net Hospital.
4 (e) The Department may promulgate rules in order to
5 implement this Section.
6 (f) Nothing in this Section shall be construed as limiting
7 the ability of the Department to include the Safety-Net
8 Hospitals in the hospital rate reform mandated by Section
9 14-11 of this Code and implemented under Section 14-12 of this
10 Code and by administrative rulemaking.
11 (Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
12 102-886, eff. 5-17-22.)
13 ARTICLE 45.
14 Section 45-5. The Hospital Licensing Act is amended by
15 changing Section 6.09 as follows:
16 (210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09)
17 Sec. 6.09. (a) In order to facilitate the orderly
18 transition of aged patients and patients with disabilities
19 from hospitals to post-hospital care, whenever a patient who
20 qualifies for the federal Medicare program is hospitalized,
21 the patient shall be notified of discharge at least 24 hours
22 prior to discharge from the hospital. With regard to pending
23 discharges to a skilled nursing facility, the hospital must
SB3365 Enrolled - 162 - LRB104 18483 SSS 31925 b
1 notify the case coordination unit, as defined in 89 Ill. Adm.
2 Code 240.260, at least 24 hours prior to discharge. When the
3 assessment is completed in the hospital, the case coordination
4 unit shall provide a copy of the required assessment
5 documentation directly to the nursing home to which the
6 patient is being discharged prior to discharge. The Department
7 on Aging shall provide notice of this requirement to case
8 coordination units. When a case coordination unit is unable to
9 complete an assessment in a hospital prior to the discharge of
10 a patient, 60 years of age or older, to a nursing home, the
11 case coordination unit shall notify the Department on Aging
12 which shall notify the Department of Healthcare and Family
13 Services. The Department on Aging shall adopt rules to address
14 these instances to ensure that the patient is able to access
15 nursing home care, the nursing home is not penalized for
16 accepting the admission, and the patient's timely discharge
17 from the hospital is not delayed, to the extent permitted
18 under federal law or regulation. Nothing in this subsection
19 shall preclude federal requirements for a pre-admission
20 screening/mental health (PAS/MH) as required under Section
21 2-201.5 of the Nursing Home Care Act or State or federal law or
22 regulation. If home health services are ordered, the hospital
23 must inform its designated case coordination unit, as defined
24 in 89 Ill. Adm. Code 240.260, of the pending discharge and must
25 provide the patient with the case coordination unit's
26 telephone number and other contact information.
SB3365 Enrolled - 163 - LRB104 18483 SSS 31925 b
1 (b) Every hospital shall develop procedures for a
2 physician with medical staff privileges at the hospital or any
3 appropriate medical staff member to provide the discharge
4 notice prescribed in subsection (a) of this Section. The
5 procedures must include prohibitions against discharging or
6 referring a patient to any of the following if unlicensed,
7 uncertified, or unregistered: (i) a board and care facility,
8 as defined in the Board and Care Home Act; (ii) an assisted
9 living and shared housing establishment, as defined in the
10 Assisted Living and Shared Housing Act; (iii) a facility
11 licensed under the Nursing Home Care Act, the Specialized
12 Mental Health Rehabilitation Act of 2013, the ID/DD Community
13 Care Act, or the MC/DD Act; (iv) a supportive living facility,
14 as defined in Section 5-5.01a of the Illinois Public Aid Code;
15 or (v) a free-standing hospice facility licensed under the
16 Hospice Program Licensing Act if licensure, certification, or
17 registration is required. The Department of Public Health
18 shall annually provide hospitals with a list of licensed,
19 certified, or registered board and care facilities, assisted
20 living and shared housing establishments, nursing homes,
21 supportive living facilities, facilities licensed under the
22 ID/DD Community Care Act, the MC/DD Act, or the Specialized
23 Mental Health Rehabilitation Act of 2013, and hospice
24 facilities. Reliance upon this list by a hospital shall
25 satisfy compliance with this requirement. The procedure may
26 also include a waiver for any case in which a discharge notice
SB3365 Enrolled - 164 - LRB104 18483 SSS 31925 b
1 is not feasible due to a short length of stay in the hospital
2 by the patient, or for any case in which the patient
3 voluntarily desires to leave the hospital before the
4 expiration of the 24 hour period.
5 (c) At least 24 hours prior to discharge from the
6 hospital, the patient shall receive written information on the
7 patient's right to appeal the discharge pursuant to the
8 federal Medicare program, including the steps to follow to
9 appeal the discharge and the appropriate telephone number to
10 call in case the patient intends to appeal the discharge.
11 (d) Before transfer of a patient to a long term care
12 facility licensed under the Nursing Home Care Act where
13 elderly persons reside, a hospital shall as soon as
14 practicable initiate a name-based criminal history background
15 check by electronic submission to the Illinois State Police
16 for all persons between the ages of 18 and 70 years; provided,
17 however, that a hospital shall be required to initiate such a
18 background check only with respect to patients who:
19 (1) are transferring to a long term care facility for
20 the first time;
21 (2) have been in the hospital more than 5 days;
22 (3) are reasonably expected to remain at the long term
23 care facility for more than 30 days;
24 (4) have a known history of serious mental illness or
25 substance abuse; and
26 (5) are independently ambulatory or mobile for more
SB3365 Enrolled - 165 - LRB104 18483 SSS 31925 b
1 than a temporary period of time.
2 A hospital may also request a criminal history background
3 check for a patient who does not meet any of the criteria set
4 forth in items (1) through (5).
5 A hospital shall notify a long term care facility if the
6 hospital has initiated a criminal history background check on
7 a patient being discharged to that facility. In all
8 circumstances in which the hospital is required by this
9 subsection to initiate the criminal history background check,
10 the transfer to the long term care facility may proceed
11 regardless of the availability of criminal history results.
12 Upon receipt of the results, the hospital shall promptly
13 forward the results to the appropriate long term care
14 facility. If the results of the background check are
15 inconclusive, the hospital shall have no additional duty or
16 obligation to seek additional information from, or about, the
17 patient.
18 (Source: P.A. 102-538, eff. 8-20-21; 103-102, eff. 1-1-24.)
19 ARTICLE 50.
20 Section 50-5. The Illinois Public Aid Code is amended by
21 changing Section 5-5.24 as follows:
22 (305 ILCS 5/5-5.24)
23 Sec. 5-5.24. Prenatal and perinatal care.
SB3365 Enrolled - 166 - LRB104 18483 SSS 31925 b
1 (a) The Department of Healthcare and Family Services may
2 provide reimbursement under this Article for all prenatal and
3 perinatal health care services that are provided for the
4 purpose of preventing low-birthweight infants, reducing the
5 need for neonatal intensive care hospital services, and
6 promoting perinatal and maternal health. These services may
7 include comprehensive risk assessments for pregnant
8 individuals, individuals with infants, and infants, lactation
9 counseling, nutrition counseling, childbirth support,
10 psychosocial counseling, treatment and prevention of
11 periodontal disease, language translation, nurse home
12 visitation, and other support services that have been proven
13 to improve birth and maternal health outcomes. The Department
14 shall maximize the use of preventive prenatal and perinatal
15 health care services consistent with federal statutes, rules,
16 and regulations. The Department of Public Aid (now Department
17 of Healthcare and Family Services) shall develop a plan for
18 prenatal and perinatal preventive health care and shall
19 present the plan to the General Assembly by January 1, 2004. On
20 or before January 1, 2006 and every 2 years thereafter, the
21 Department shall report to the General Assembly concerning the
22 effectiveness of prenatal and perinatal health care services
23 reimbursed under this Section in preventing low-birthweight
24 infants and reducing the need for neonatal intensive care
25 hospital services. Each such report shall include an
26 evaluation of how the ratio of expenditures for treating
SB3365 Enrolled - 167 - LRB104 18483 SSS 31925 b
1 low-birthweight infants compared with the investment in
2 promoting healthy births and infants in local community areas
3 throughout Illinois relates to healthy infant development in
4 those areas.
5 On and after July 1, 2012, the Department shall reduce any
6 rate of reimbursement for services or other payments or alter
7 any methodologies authorized by this Code to reduce any rate
8 of reimbursement for services or other payments in accordance
9 with Section 5-5e.
10 (b)(1) As used in this subsection:
11 "Affiliated provider" means a provider who is enrolled in
12 the medical assistance program and has an active contract with
13 a managed care organization.
14 "Non-affiliated provider" means a provider who is enrolled
15 in the medical assistance program but does not have a contract
16 with an MCO.
17 "Preventive prenatal and perinatal health care services"
18 means services described in subsection (a) including the
19 following non-emergent diagnostic and ancillary services:
20 (i) Diagnostic labs and imaging, including level II
21 ultrasounds.
22 (ii) RhoGAM injections.
23 (iii) Injectable 17-alpha-hydroxyprogesterone
24 caproate (commonly called 17P).
25 (iv) Intrapartum (labor and delivery) services.
26 (v) Any other outpatient or inpatient service relating
SB3365 Enrolled - 168 - LRB104 18483 SSS 31925 b
1 to pregnancy or the 12 months following childbirth or
2 fetal loss.
3 (2) In order to maximize the accessibility of preventive
4 prenatal and perinatal health care services, the Department of
5 Healthcare and Family Services shall amend its managed care
6 contracts such that an MCO must pay for preventive prenatal
7 services, perinatal healthcare services, and postpartum
8 services rendered by a non-affiliated provider, for which the
9 health plan would pay if rendered by an affiliated provider,
10 at the rate paid under the Illinois Medicaid fee-for-service
11 program methodology for such services, including all policy
12 adjusters, including, but not limited to, Medicaid High Volume
13 Adjustments, Medicaid Percentage Adjustments, Outpatient High
14 Volume Adjustments, and all outlier add-on adjustments to the
15 extent such adjustments are incorporated in the development of
16 the applicable MCO capitated rates, unless a different rate
17 was agreed upon by the health plan and the non-affiliated
18 provider.
19 (3) In cases where a managed care organization must pay
20 for preventive prenatal services, perinatal healthcare
21 services, and postpartum services rendered by a non-affiliated
22 provider, the requirements under paragraph (2) shall not apply
23 if the services were not emergency services, as defined in
24 Section 5-30.1, and:
25 (A) the non-affiliated provider is a perinatal
26 hospital and has, within the 12 months preceding the date
SB3365 Enrolled - 169 - LRB104 18483 SSS 31925 b
1 of service, rejected a contract that was offered in good
2 faith by the health plan as determined by the Department;
3 or
4 (B) the health plan has terminated a contract with the
5 non-affiliated provider for cause, and the Department has
6 not deemed the termination to have been without merit. The
7 Department may deem that a determination for cause has
8 merit if:
9 (i) an institutional provider has repeatedly
10 failed to conduct discharge planning; or
11 (ii) the provider's conduct adversely and
12 substantially impacts the health of Medicaid patients;
13 or
14 (iii) the provider's conduct constitutes fraud,
15 waste, or abuse; or
16 (iv) the provider's conduct violates the code of
17 ethics governing his or her profession.
18 (4) For dates of service on and after January 1, 2026, the
19 medical assistance program shall provide coverage, without
20 imposing a deductible, coinsurance, copayment, or any other
21 cost-sharing requirement, for preeclampsia biomarker testing
22 for predictive screening in asymptomatic individuals, or for
23 diagnosis and management when symptoms are present.
24 (Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)
25 ARTICLE 55.
SB3365 Enrolled - 170 - LRB104 18483 SSS 31925 b
1 Section 55-5. The Specialized Mental Health Rehabilitation
2 Act of 2013 is amended by changing Sections 2-101 and 3-104 as
3 follows:
4 (210 ILCS 49/2-101)
5 Sec. 2-101. Standards for facilities.
6 (a) The Department shall, by rule, prescribe minimum
7 standards for each level of care for facilities to be in place
8 during the provisional licensure period and thereafter. These
9 standards shall include, but are not limited to, the
10 following:
11 (1) life safety standards that will ensure the health,
12 safety and welfare of residents and their protection from
13 hazards;
14 (2) number and qualifications of all personnel,
15 including management and clinical personnel, having
16 responsibility for any part of the care given to
17 consumers; specifically, the Department shall establish
18 staffing ratios for facilities which shall specify the
19 number of staff hours per consumer of care that are needed
20 for each level of care offered within the facility;
21 (3) all sanitary conditions within the facility and
22 its surroundings, including water supply, sewage disposal,
23 food handling, and general hygiene which shall ensure the
24 health and comfort of consumers;
SB3365 Enrolled - 171 - LRB104 18483 SSS 31925 b
1 (4) a program for adequate maintenance of physical
2 plant and equipment;
3 (5) adequate accommodations, staff, and services for
4 the number and types of services being offered to
5 consumers for whom the facility is licensed to care;
6 (6) development of evacuation and other appropriate
7 safety plans for use during weather, health, fire,
8 physical plant, environmental, and national defense
9 emergencies;
10 (7) maintenance of minimum financial or other
11 resources necessary to meet the standards established
12 under this Section, and to operate and conduct the
13 facility in accordance with this Act;
14 (8) standards for coercive free environment,
15 restraint, and therapeutic separation; and
16 (9) each multiple bedroom shall have at least 55
17 square feet of net floor area per consumer, not including
18 space for closets, bathrooms, and clearly defined entryway
19 areas. A minimum of 3 feet of clearance at the foot and one
20 side of each bed shall be provided.
21 (b) Any requirement contained in administrative rule
22 concerning a percentage of single occupancy rooms shall be
23 calculated based on the total number of licensed or
24 provisionally licensed beds under this Act on January 1, 2019
25 and shall not be calculated on a per-facility basis.
26 (c) A facility licensed under this Act shall not accept
SB3365 Enrolled - 172 - LRB104 18483 SSS 31925 b
1 any person experiencing an acute medical condition liable to
2 cause death, severe injury, or serious illness.
3 (Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21.)
4 (210 ILCS 49/3-104)
5 Sec. 3-104. Care, treatment, and records. Facilities shall
6 provide, at a minimum, the following services: physician,
7 nursing, pharmaceutical, rehabilitative, and dietary services.
8 To provide these services, the facility shall adhere to the
9 following:
10 (1) Each consumer shall be encouraged and assisted to
11 achieve and maintain the highest level of self-care and
12 independence. Every effort shall be made to keep consumers
13 active and out of bed for reasonable periods of time,
14 except when contraindicated by physician orders.
15 (2) Every consumer shall be engaged in a
16 person-centered planning process regarding his or her
17 total care and treatment.
18 (3) All medical treatment and procedures shall be
19 administered as ordered by a physician. All new physician
20 orders shall be reviewed by the facility's director of
21 nursing or charge nurse designee within 24 hours after
22 such orders have been issued to ensure facility compliance
23 with such orders. According to rules adopted by the
24 Department, every woman consumer of child bearing age
25 shall receive routine obstetrical and gynecological
SB3365 Enrolled - 173 - LRB104 18483 SSS 31925 b
1 evaluations as well as necessary prenatal care.
2 (4) Each consumer shall be provided with good
3 nutrition and with necessary fluids for hydration.
4 (5) Each consumer shall be provided visual privacy
5 during treatment and personal care.
6 (6) Every consumer or consumer's guardian shall be
7 permitted to inspect and copy all his or her clinical and
8 other records concerning his or her care kept by the
9 facility or by his or her physician. The facility may
10 charge a reasonable fee for duplication of a record.
11 (7) Each consumer shall be offered at least 15 hours
12 of treatment programming per week and shall be encouraged
13 to attend the treatment domains that meet the consumer's
14 needs, as reflected in the consumer's treatment plans.
15 Each consumer's program engagement and attendance shall be
16 documented in the consumer's clinical record, and each
17 consumer shall be prompted to attend programming regularly
18 as documented in the consumer's clinical record at least
19 quarterly.
20 (Source: P.A. 98-104, eff. 7-22-13.)
21 ARTICLE 60.
22 Section 60-5. The Illinois Public Aid Code is amended by
23 adding Section 5-5.25a as follows:
SB3365 Enrolled - 174 - LRB104 18483 SSS 31925 b
1 (305 ILCS 5/5-5.25a new)
2 Sec. 5-5.25a. Coverage for seizure detection devices.
3 (a) As used in this Section, "seizure detection device"
4 means a monitoring device cleared by the United States Food
5 and Drug Administration, and any related technology,
6 application, service, or subscription supporting the
7 prescribed use of the device, that provides the following:
8 (1) individual monitoring and alert services relating
9 to seizure activity;
10 (2) detection or prediction of seizure activity and
11 transmission of notification of the seizure activity to
12 the individual or a caregiver for appropriate medical
13 response; or
14 (3) collection of data of the seizure activity of the
15 individual that can be used by a health care provider to
16 diagnose or appropriately treat a health care condition
17 that causes the seizure activity.
18 (b) All seizure detection devices covered under this
19 Section shall be approved for use by individuals, provided
20 that the device has been prescribed and determined to be
21 medically necessary. The choice of device shall be made based
22 upon the individual's circumstances and medical needs in
23 consultation with the individual's medical provider.
24 (c) Any individual who has been prescribed a seizure
25 detection device shall not be required to obtain prior
26 authorization for coverage for a seizure detection device, and
SB3365 Enrolled - 175 - LRB104 18483 SSS 31925 b
1 coverage shall be continuous once the seizure detection device
2 is prescribed.
3 (d) Notwithstanding any other provision of this Section,
4 commencing July 1, 2027, all seizure detection devices cleared
5 by the United States Food and Drug Administration shall be
6 covered under the medical assistance program for persons who
7 have been prescribed a seizure detection device and who are
8 otherwise eligible for assistance under this Article.
9 (e) The Department shall not adopt rules or classification
10 policies that would limit the ability of individuals covered
11 by this Section to obtain seizure detection devices.
12 ARTICLE 65.
13 Section 65-5. The Community-Integrated Living Arrangements
14 Licensure and Certification Act is amended by changing Section
15 13.3 as follows:
16 (210 ILCS 135/13.3)
17 Sec. 13.3. Community-integrated living arrangement per
18 diem reimbursement. As used in this Section, "medical absence"
19 means a situation in which a resident is temporarily absent
20 from a community-integrated living arrangement to receive
21 medical treatment or for other reasons that have been
22 recommended by third-party medical personnel, including, but
23 not limited to, hospitalizations, placements in short-term
SB3365 Enrolled - 176 - LRB104 18483 SSS 31925 b
1 stabilization homes or State-operated facilities, stays in
2 nursing facilities, rehabilitation in long-term care
3 facilities, or other absences for legitimate medical reasons.
4 Beginning January 1, 2025, the Department's Division of
5 Developmental Disabilities shall provide 100% of the per diem
6 reimbursement to a 24-hour community-integrated living
7 arrangement provider for up to 20 days for any resident
8 requiring a medical absence. During the medical absence, the
9 provider shall hold the bed for the resident. After the
10 medical absence, the resident shall return to the
11 community-integrated living arrangement when the resident is
12 medically able to return in order for the provider to receive
13 the full per diem reimbursement for the absent days. However,
14 if it is determined by a treating physician that the resident
15 is unable to return to the community-integrated living
16 arrangement, or if the resident dies during the medical
17 absence, the provider shall receive 100% of the per diem
18 reimbursement for up to 20 medical absence days. The per diem
19 reimbursement shall be in addition to the existing occupancy
20 factor policy set by the Division of Developmental
21 Disabilities. Any Department policy or rulemaking issued to
22 implement this Section shall provide that for medical absences
23 a resident's termination date is the date the resident either
24 passes away or the date it is determined by a treating
25 physician that the resident is unable to return to the
26 community-integrated living arrangement.
SB3365 Enrolled - 177 - LRB104 18483 SSS 31925 b
1 (Source: P.A. 103-593, eff. 6-7-24.)
2 ARTICLE 75.
3 Section 75-5. The Illinois Public Aid Code is amended by
4 changing Section 5-5.02 as follows:
5 (305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
6 Sec. 5-5.02. Hospital reimbursements.
7 (a) Reimbursement to hospitals; July 1, 1992 through
8 September 30, 1992. Notwithstanding any other provisions of
9 this Code or the Illinois Department's Rules promulgated under
10 the Illinois Administrative Procedure Act, reimbursement to
11 hospitals for services provided during the period July 1, 1992
12 through September 30, 1992, shall be as follows:
13 (1) For inpatient hospital services rendered, or if
14 applicable, for inpatient hospital discharges occurring,
15 on or after July 1, 1992 and on or before September 30,
16 1992, the Illinois Department shall reimburse hospitals
17 for inpatient services under the reimbursement
18 methodologies in effect for each hospital, and at the
19 inpatient payment rate calculated for each hospital, as of
20 June 30, 1992. For purposes of this paragraph,
21 "reimbursement methodologies" means all reimbursement
22 methodologies that pertain to the provision of inpatient
23 hospital services, including, but not limited to, any
SB3365 Enrolled - 178 - LRB104 18483 SSS 31925 b
1 adjustments for disproportionate share, targeted access,
2 critical care access and uncompensated care, as defined by
3 the Illinois Department on June 30, 1992.
4 (2) For the purpose of calculating the inpatient
5 payment rate for each hospital eligible to receive
6 quarterly adjustment payments for targeted access and
7 critical care, as defined by the Illinois Department on
8 June 30, 1992, the adjustment payment for the period July
9 1, 1992 through September 30, 1992, shall be 25% of the
10 annual adjustment payments calculated for each eligible
11 hospital, as of June 30, 1992. The Illinois Department
12 shall determine by rule the adjustment payments for
13 targeted access and critical care beginning October 1,
14 1992.
15 (3) For the purpose of calculating the inpatient
16 payment rate for each hospital eligible to receive
17 quarterly adjustment payments for uncompensated care, as
18 defined by the Illinois Department on June 30, 1992, the
19 adjustment payment for the period August 1, 1992 through
20 September 30, 1992, shall be one-sixth of the total
21 uncompensated care adjustment payments calculated for each
22 eligible hospital for the uncompensated care rate year, as
23 defined by the Illinois Department, ending on July 31,
24 1992. The Illinois Department shall determine by rule the
25 adjustment payments for uncompensated care beginning
26 October 1, 1992.
SB3365 Enrolled - 179 - LRB104 18483 SSS 31925 b
1 (b) Inpatient payments. For inpatient services provided on
2 or after October 1, 1993, in addition to rates paid for
3 hospital inpatient services pursuant to the Illinois Health
4 Finance Reform Act, as now or hereafter amended, or the
5 Illinois Department's prospective reimbursement methodology,
6 or any other methodology used by the Illinois Department for
7 inpatient services, the Illinois Department shall make
8 adjustment payments, in an amount calculated pursuant to the
9 methodology described in paragraph (c) of this Section, to
10 hospitals that the Illinois Department determines satisfy any
11 one of the following requirements:
12 (1) Hospitals that are described in Section 1923 of
13 the federal Social Security Act, as now or hereafter
14 amended, except that for rate year 2015 and after a
15 hospital described in Section 1923(b)(1)(B) of the federal
16 Social Security Act and qualified for the payments
17 described in subsection (c) of this Section for rate year
18 2014 provided the hospital continues to meet the
19 description in Section 1923(b)(1)(B) in the current
20 determination year; or
21 (2) Illinois hospitals that have a Medicaid inpatient
22 utilization rate which is at least one-half a standard
23 deviation above the mean Medicaid inpatient utilization
24 rate for all hospitals in Illinois receiving Medicaid
25 payments from the Illinois Department; or
26 (3) Illinois hospitals that on July 1, 1991 had a
SB3365 Enrolled - 180 - LRB104 18483 SSS 31925 b
1 Medicaid inpatient utilization rate, as defined in
2 paragraph (h) of this Section, that was at least the mean
3 Medicaid inpatient utilization rate for all hospitals in
4 Illinois receiving Medicaid payments from the Illinois
5 Department and which were located in a planning area with
6 one-third or fewer excess beds as determined by the Health
7 Facilities and Services Review Board, and that, as of June
8 30, 1992, were located in a federally designated Health
9 Manpower Shortage Area; or
10 (4) Illinois hospitals that:
11 (A) have a Medicaid inpatient utilization rate
12 that is at least equal to the mean Medicaid inpatient
13 utilization rate for all hospitals in Illinois
14 receiving Medicaid payments from the Department; and
15 (B) also have a Medicaid obstetrical inpatient
16 utilization rate that is at least one standard
17 deviation above the mean Medicaid obstetrical
18 inpatient utilization rate for all hospitals in
19 Illinois receiving Medicaid payments from the
20 Department for obstetrical services; or
21 (5) Any children's hospital, which means a hospital
22 devoted exclusively to caring for children. A hospital
23 which includes a facility devoted exclusively to caring
24 for children shall be considered a children's hospital to
25 the degree that the hospital's Medicaid care is provided
26 to children if either (i) the facility devoted exclusively
SB3365 Enrolled - 181 - LRB104 18483 SSS 31925 b
1 to caring for children is separately licensed as a
2 hospital by a municipality prior to February 28, 2013;
3 (ii) the hospital has been designated by the State as a
4 Level III perinatal care facility, has a Medicaid
5 Inpatient Utilization rate greater than 55% for the rate
6 year 2003 disproportionate share determination, and has
7 more than 10,000 qualified children days as defined by the
8 Department in rulemaking; (iii) the hospital has been
9 designated as a Perinatal Level III center by the State as
10 of December 1, 2017, is a Pediatric Critical Care Center
11 designated by the State as of December 1, 2017 and has a
12 2017 Medicaid inpatient utilization rate equal to or
13 greater than 45%; or (iv) the hospital has been designated
14 as a Perinatal Level II center by the State as of December
15 1, 2017, has a 2017 Medicaid Inpatient Utilization Rate
16 greater than 70%, and has at least 10 pediatric beds as
17 listed on the IDPH 2015 calendar year hospital profile; or
18 (6) A hospital that reopens a previously closed
19 hospital facility within 4 calendar years of the hospital
20 facility's closure, if the previously closed hospital
21 facility qualified for payments under paragraph (c) at the
22 time of closure, until utilization data for the new
23 facility is available for the Medicaid inpatient
24 utilization rate calculation. For purposes of this clause,
25 a "closed hospital facility" shall include hospitals that
26 have been terminated from participation in the medical
SB3365 Enrolled - 182 - LRB104 18483 SSS 31925 b
1 assistance program in accordance with Section 12-4.25 of
2 this Code.
3 (c) Inpatient adjustment payments. The adjustment payments
4 required by paragraph (b) shall be calculated based upon the
5 hospital's Medicaid inpatient utilization rate as follows:
6 (1) hospitals with a Medicaid inpatient utilization
7 rate below the mean shall receive a per day adjustment
8 payment equal to $25;
9 (2) hospitals with a Medicaid inpatient utilization
10 rate that is equal to or greater than the mean Medicaid
11 inpatient utilization rate but less than one standard
12 deviation above the mean Medicaid inpatient utilization
13 rate shall receive a per day adjustment payment equal to
14 the sum of $25 plus $1 for each one percent that the
15 hospital's Medicaid inpatient utilization rate exceeds the
16 mean Medicaid inpatient utilization rate;
17 (3) hospitals with a Medicaid inpatient utilization
18 rate that is equal to or greater than one standard
19 deviation above the mean Medicaid inpatient utilization
20 rate but less than 1.5 standard deviations above the mean
21 Medicaid inpatient utilization rate shall receive a per
22 day adjustment payment equal to the sum of $40 plus $7 for
23 each one percent that the hospital's Medicaid inpatient
24 utilization rate exceeds one standard deviation above the
25 mean Medicaid inpatient utilization rate;
26 (4) hospitals with a Medicaid inpatient utilization
SB3365 Enrolled - 183 - LRB104 18483 SSS 31925 b
1 rate that is equal to or greater than 1.5 standard
2 deviations above the mean Medicaid inpatient utilization
3 rate shall receive a per day adjustment payment equal to
4 the sum of $90 plus $2 for each one percent that the
5 hospital's Medicaid inpatient utilization rate exceeds 1.5
6 standard deviations above the mean Medicaid inpatient
7 utilization rate; and
8 (5) hospitals qualifying under clause (6) of paragraph
9 (b) shall have the rate assigned to the previously closed
10 hospital facility at the date of closure, until
11 utilization data for the new facility is available for the
12 Medicaid inpatient utilization rate calculation.
13 (c-1) Beginning October 1, 2026, for rate year 2027 and
14 thereafter, the Medicaid inpatient utilization rate used in
15 the determination of eligibility for payments under paragraph
16 (c) shall be modified to exclude from both the numerator and
17 denominator all days of care funded by the U.S. Department of
18 Veterans Affairs at a hospital approved to conduct its
19 operations from more than one location within contiguous
20 counties under a single license, if at the time of its
21 licensing application the hospital was located in a county
22 with fewer than 125,000 inhabitants and the hospital's second
23 facility is located in a contiguous county with fewer than
24 235,000 inhabitants. For purposes of this subsection, days of
25 care funded by the U.S. Department of Veterans Affairs include
26 authorized VA community care provided at non-VA hospitals.
SB3365 Enrolled - 184 - LRB104 18483 SSS 31925 b
1 (d) Supplemental adjustment payments. In addition to the
2 adjustment payments described in paragraph (c), hospitals as
3 defined in clauses (1) through (6) of paragraph (b), excluding
4 county hospitals (as defined in subsection (c) of Section 15-1
5 of this Code) and a hospital organized under the University of
6 Illinois Hospital Act, shall be paid supplemental inpatient
7 adjustment payments of $60 per day. For purposes of Title XIX
8 of the federal Social Security Act, these supplemental
9 adjustment payments shall not be classified as adjustment
10 payments to disproportionate share hospitals.
11 (e) The inpatient adjustment payments described in
12 paragraphs (c) and (d) shall be increased on October 1, 1993
13 and annually thereafter by a percentage equal to the lesser of
14 (i) the increase in the DRI hospital cost index for the most
15 recent 12 month period for which data are available, or (ii)
16 the percentage increase in the statewide average hospital
17 payment rate over the previous year's statewide average
18 hospital payment rate. The sum of the inpatient adjustment
19 payments under paragraphs (c) and (d) to a hospital, other
20 than a county hospital (as defined in subsection (c) of
21 Section 15-1 of this Code) or a hospital organized under the
22 University of Illinois Hospital Act, however, shall not exceed
23 $275 per day; that limit shall be increased on October 1, 1993
24 and annually thereafter by a percentage equal to the lesser of
25 (i) the increase in the DRI hospital cost index for the most
26 recent 12-month period for which data are available or (ii)
SB3365 Enrolled - 185 - LRB104 18483 SSS 31925 b
1 the percentage increase in the statewide average hospital
2 payment rate over the previous year's statewide average
3 hospital payment rate.
4 (f) Children's hospital inpatient adjustment payments. For
5 children's hospitals, as defined in clause (5) of paragraph
6 (b), the adjustment payments required pursuant to paragraphs
7 (c) and (d) shall be multiplied by 2.0.
8 (g) County hospital inpatient adjustment payments. For
9 county hospitals, as defined in subsection (c) of Section 15-1
10 of this Code, there shall be an adjustment payment as
11 determined by rules issued by the Illinois Department.
12 (h) For the purposes of this Section the following terms
13 shall be defined as follows:
14 (1) "Medicaid inpatient utilization rate" means a
15 fraction, the numerator of which is the number of a
16 hospital's inpatient days provided in a given 12-month
17 period to patients who, for such days, were eligible for
18 Medicaid under Title XIX of the federal Social Security
19 Act, and the denominator of which is the total number of
20 the hospital's inpatient days in that same period.
21 (2) "Mean Medicaid inpatient utilization rate" means
22 the total number of Medicaid inpatient days provided by
23 all Illinois Medicaid-participating hospitals divided by
24 the total number of inpatient days provided by those same
25 hospitals.
26 (3) "Medicaid obstetrical inpatient utilization rate"
SB3365 Enrolled - 186 - LRB104 18483 SSS 31925 b
1 means the ratio of Medicaid obstetrical inpatient days to
2 total Medicaid inpatient days for all Illinois hospitals
3 receiving Medicaid payments from the Illinois Department.
4 (i) Inpatient adjustment payment limit. In order to meet
5 the limits of Public Law 102-234 and Public Law 103-66, the
6 Illinois Department shall by rule adjust disproportionate
7 share adjustment payments.
8 (j) University of Illinois Hospital inpatient adjustment
9 payments. For hospitals organized under the University of
10 Illinois Hospital Act, there shall be an adjustment payment as
11 determined by rules adopted by the Illinois Department.
12 (k) The Illinois Department may by rule establish criteria
13 for and develop methodologies for adjustment payments to
14 hospitals participating under this Article.
15 (l) On and after July 1, 2012, the Department shall reduce
16 any rate of reimbursement for services or other payments or
17 alter any methodologies authorized by this Code to reduce any
18 rate of reimbursement for services or other payments in
19 accordance with Section 5-5e.
20 (m) The Department shall establish a cost-based
21 reimbursement methodology for determining payments to
22 hospitals for approved graduate medical education (GME)
23 programs for dates of service on and after July 1, 2018.
24 (1) As used in this subsection, "hospitals" means the
25 University of Illinois Hospital as defined in the
26 University of Illinois Hospital Act and a county hospital
SB3365 Enrolled - 187 - LRB104 18483 SSS 31925 b
1 in a county of over 3,000,000 inhabitants.
2 (2) An amendment to the Illinois Title XIX State Plan
3 defining GME shall maximize reimbursement, shall not be
4 limited to the education programs or special patient care
5 payments allowed under Medicare, and shall include:
6 (A) inpatient days;
7 (B) outpatient days;
8 (C) direct costs;
9 (D) indirect costs;
10 (E) managed care days;
11 (F) all stages of medical training and education
12 including students, interns, residents, and fellows
13 with no caps on the number of persons who may qualify;
14 and
15 (G) patient care payments related to the
16 complexities of treating Medicaid enrollees including
17 clinical and social determinants of health.
18 (3) The Department shall make all GME payments
19 directly to hospitals including such costs in support of
20 clients enrolled in Medicaid managed care entities.
21 (4) The Department shall promptly take all actions
22 necessary for reimbursement to be effective for dates of
23 service on and after July 1, 2018 including publishing all
24 appropriate public notices, amendments to the Illinois
25 Title XIX State Plan, and adoption of administrative rules
26 if necessary.
SB3365 Enrolled - 188 - LRB104 18483 SSS 31925 b
1 (5) As used in this subsection, "managed care days"
2 means costs associated with services rendered to enrollees
3 of Medicaid managed care entities. "Medicaid managed care
4 entities" means any entity which contracts with the
5 Department to provide services paid for on a capitated
6 basis. "Medicaid managed care entities" includes a managed
7 care organization and a managed care community network.
8 (6) All payments under this Section are contingent
9 upon federal approval of changes to the Illinois Title XIX
10 State Plan, if that approval is required.
11 (7) The Department may adopt rules necessary to
12 implement Public Act 100-581 through the use of emergency
13 rulemaking in accordance with subsection (aa) of Section
14 5-45 of the Illinois Administrative Procedure Act. For
15 purposes of that Act, the General Assembly finds that the
16 adoption of rules to implement Public Act 100-581 is
17 deemed an emergency and necessary for the public interest,
18 safety, and welfare.
19 (Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21;
20 102-886, eff. 5-17-22.)
21 ARTICLE 85.
22 Section 85-5. The Illinois Act on the Aging is amended by
23 changing Section 4.02 as follows:
SB3365 Enrolled - 189 - LRB104 18483 SSS 31925 b
1 (20 ILCS 105/4.02)
2 Sec. 4.02. Community Care Program. The Department shall
3 establish a program of services to prevent unnecessary
4 institutionalization of persons age 60 and older in need of
5 long term care or who are established as persons who suffer
6 from Alzheimer's disease or a related disorder under the
7 Alzheimer's Disease Assistance Act, thereby enabling them to
8 remain in their own homes or in other living arrangements.
9 Such preventive services, which may be coordinated with other
10 programs for the aged, may include, but are not limited to, any
11 or all of the following:
12 (a) (blank);
13 (b) (blank);
14 (c) home care aide services;
15 (d) personal assistant services;
16 (e) adult day services;
17 (f) home-delivered meals;
18 (g) education in self-care;
19 (h) personal care services;
20 (i) adult day health services;
21 (j) habilitation services;
22 (k) respite care;
23 (k-5) community reintegration services;
24 (k-6) flexible senior services;
25 (k-7) medication management;
26 (k-8) emergency home response;
SB3365 Enrolled - 190 - LRB104 18483 SSS 31925 b
1 (l) other nonmedical social services that may enable
2 the person to become self-supporting; or
3 (m) (blank).
4 The Department shall establish eligibility standards for
5 such services. In determining the amount and nature of
6 services for which a person may qualify, consideration shall
7 not be given to the value of cash, property, or other assets
8 held in the name of the person's spouse pursuant to a written
9 agreement dividing marital property into equal but separate
10 shares or pursuant to a transfer of the person's interest in a
11 home to his spouse, provided that the spouse's share of the
12 marital property is not made available to the person seeking
13 such services.
14 The Department shall require as a condition of eligibility
15 that all new financially eligible applicants apply for and
16 enroll in medical assistance under Article V of the Illinois
17 Public Aid Code in accordance with rules promulgated by the
18 Department.
19 The Department shall, in conjunction with the Department
20 of Public Aid (now Department of Healthcare and Family
21 Services), seek appropriate amendments under Sections 1915 and
22 1924 of the Social Security Act. The purpose of the amendments
23 shall be to extend eligibility for home and community based
24 services under Sections 1915 and 1924 of the Social Security
25 Act to persons who transfer to or for the benefit of a spouse
26 those amounts of income and resources allowed under Section
SB3365 Enrolled - 191 - LRB104 18483 SSS 31925 b
1 1924 of the Social Security Act. Subject to the approval of
2 such amendments, the Department shall extend the provisions of
3 Section 5-4 of the Illinois Public Aid Code to persons who, but
4 for the provision of home or community-based services, would
5 require the level of care provided in an institution, as is
6 provided for in federal law. Those persons no longer found to
7 be eligible for receiving noninstitutional services due to
8 changes in the eligibility criteria shall be given 45 days
9 notice prior to actual termination. Those persons receiving
10 notice of termination may contact the Department and request
11 the determination be appealed at any time during the 45 day
12 notice period. The target population identified for the
13 purposes of this Section are persons age 60 and older with an
14 identified service need. Priority shall be given to those who
15 are at imminent risk of institutionalization. The services
16 shall be provided to eligible persons age 60 and older to the
17 extent that the cost of the services together with the other
18 personal maintenance expenses of the persons are reasonably
19 related to the standards established for care in a group
20 facility appropriate to the person's condition. These
21 noninstitutional services, pilot projects, or experimental
22 facilities may be provided as part of or in addition to those
23 authorized by federal law or those funded and administered by
24 the Department of Human Services. The Departments of Human
25 Services, Healthcare and Family Services, Public Health,
26 Veterans' Affairs, and Commerce and Economic Opportunity and
SB3365 Enrolled - 192 - LRB104 18483 SSS 31925 b
1 other appropriate agencies of State, federal, and local
2 governments shall cooperate with the Department on Aging in
3 the establishment and development of the noninstitutional
4 services. The Department shall require an annual audit from
5 all personal assistant and home care aide vendors contracting
6 with the Department under this Section. The annual audit shall
7 assure that each audited vendor's procedures are in compliance
8 with Department's financial reporting guidelines requiring an
9 administrative and employee wage and benefits cost split as
10 defined in administrative rules. The audit is a public record
11 under the Freedom of Information Act. The Department shall
12 execute, relative to the nursing home prescreening project,
13 written inter-agency agreements with the Department of Human
14 Services and the Department of Healthcare and Family Services,
15 to effect the following: (1) intake procedures and common
16 eligibility criteria for those persons who are receiving
17 noninstitutional services; and (2) the establishment and
18 development of noninstitutional services in areas of the State
19 where they are not currently available or are undeveloped. On
20 and after July 1, 1996, all nursing home prescreenings for
21 individuals 60 years of age or older shall be conducted by the
22 Department.
23 As part of the Department on Aging's routine training of
24 case managers and case manager supervisors, the Department may
25 include information on family futures planning for persons who
26 are age 60 or older and who are caregivers of their adult
SB3365 Enrolled - 193 - LRB104 18483 SSS 31925 b
1 children with developmental disabilities. The content of the
2 training shall be at the Department's discretion.
3 The Department is authorized to establish a system of
4 recipient copayment for services provided under this Section,
5 such copayment to be based upon the recipient's ability to pay
6 but in no case to exceed the actual cost of the services
7 provided. Additionally, any portion of a person's income which
8 is equal to or less than the federal poverty standard shall not
9 be considered by the Department in determining the copayment.
10 The level of such copayment shall be adjusted whenever
11 necessary to reflect any change in the officially designated
12 federal poverty standard.
13 The Department, or the Department's authorized
14 representative, may recover the amount of moneys expended for
15 services provided to or in behalf of a person under this
16 Section by a claim against the person's estate or against the
17 estate of the person's surviving spouse, but no recovery may
18 be had until after the death of the surviving spouse, if any,
19 and then only at such time when there is no surviving child who
20 is under age 21 or blind or who has a permanent and total
21 disability. This paragraph, however, shall not bar recovery,
22 at the death of the person, of moneys for services provided to
23 the person or in behalf of the person under this Section to
24 which the person was not entitled; provided that such recovery
25 shall not be enforced against any real estate while it is
26 occupied as a homestead by the surviving spouse or other
SB3365 Enrolled - 194 - LRB104 18483 SSS 31925 b
1 dependent, if no claims by other creditors have been filed
2 against the estate, or, if such claims have been filed, they
3 remain dormant for failure of prosecution or failure of the
4 claimant to compel administration of the estate for the
5 purpose of payment. This paragraph shall not bar recovery from
6 the estate of a spouse, under Sections 1915 and 1924 of the
7 Social Security Act and Section 5-4 of the Illinois Public Aid
8 Code, who precedes a person receiving services under this
9 Section in death. All moneys for services paid to or in behalf
10 of the person under this Section shall be claimed for recovery
11 from the deceased spouse's estate. "Homestead", as used in
12 this paragraph, means the dwelling house and contiguous real
13 estate occupied by a surviving spouse or relative, as defined
14 by the rules and regulations of the Department of Healthcare
15 and Family Services, regardless of the value of the property.
16 The Department shall increase the effectiveness of the
17 existing Community Care Program by:
18 (1) ensuring that in-home services included in the
19 care plan are available on evenings and weekends;
20 (2) ensuring that care plans contain the services that
21 eligible participants need based on the number of days in
22 a month, not limited to specific blocks of time, as
23 identified by the comprehensive assessment tool selected
24 by the Department for use statewide, not to exceed the
25 total monthly service cost maximum allowed for each
26 service; the Department shall develop administrative rules
SB3365 Enrolled - 195 - LRB104 18483 SSS 31925 b
1 to implement this item (2);
2 (3) ensuring that the participants have the right to
3 choose the services contained in their care plan and to
4 direct how those services are provided, based on
5 administrative rules established by the Department;
6 (4)(blank);
7 (5) ensuring that homemakers can provide personal care
8 services that may or may not involve contact with clients,
9 including, but not limited to:
10 (A) bathing;
11 (B) grooming;
12 (C) toileting;
13 (D) nail care;
14 (E) transferring;
15 (F) respiratory services;
16 (G) exercise; or
17 (H) positioning;
18 (6) ensuring that homemaker program vendors are not
19 restricted from hiring homemakers who are family members
20 of clients or recommended by clients; the Department may
21 not, by rule or policy, require homemakers who are family
22 members of clients or recommended by clients to accept
23 assignments in homes other than the client;
24 (7) ensuring that the State may access maximum federal
25 matching funds by seeking approval for the Centers for
26 Medicare and Medicaid Services for modifications to the
SB3365 Enrolled - 196 - LRB104 18483 SSS 31925 b
1 State's home and community based services waiver and
2 additional waiver opportunities, including applying for
3 enrollment in the Balance Incentive Payment Program by May
4 1, 2013, in order to maximize federal matching funds; this
5 shall include, but not be limited to, modification that
6 reflects all changes in the Community Care Program
7 services and all increases in the services cost maximum;
8 (8) ensuring that the determination of need tool
9 accurately reflects the service needs of individuals with
10 Alzheimer's disease and related dementia disorders;
11 (9) ensuring that services are authorized accurately
12 and consistently for the Community Care Program (CCP); the
13 Department shall implement a Service Authorization policy
14 directive; the purpose shall be to ensure that eligibility
15 and services are authorized accurately and consistently in
16 the CCP program; the policy directive shall clarify
17 service authorization guidelines to Care Coordination
18 Units and Community Care Program providers no later than
19 May 1, 2013;
20 (10) working in conjunction with Care Coordination
21 Units, the Department of Healthcare and Family Services,
22 the Department of Human Services, Community Care Program
23 providers, and other stakeholders to make improvements to
24 the Medicaid claiming processes and the Medicaid
25 enrollment procedures or requirements as needed,
26 including, but not limited to, specific policy changes or
SB3365 Enrolled - 197 - LRB104 18483 SSS 31925 b
1 rules to improve the up-front enrollment of participants
2 in the Medicaid program and specific policy changes or
3 rules to ensure insure more prompt submission of bills to
4 the federal government to secure maximum federal matching
5 dollars as promptly as possible; the Department on Aging
6 shall have at least 3 meetings with stakeholders by
7 January 1, 2014 in order to address these improvements;
8 (11) requiring home care service providers to comply
9 with the rounding of hours worked provisions under the
10 federal Fair Labor Standards Act (FLSA) and as set forth
11 in 29 CFR 785.48(b) by May 1, 2013;
12 (12) implementing any necessary policy changes or
13 promulgating any rules, no later than January 1, 2014, to
14 assist the Department of Healthcare and Family Services in
15 moving as many participants as possible, consistent with
16 federal regulations, into coordinated care plans if a care
17 coordination plan that covers long term care is available
18 in the recipient's area; and
19 (13) (blank).
20 By January 1, 2009 or as soon after the end of the Cash and
21 Counseling Demonstration Project as is practicable, the
22 Department may, based on its evaluation of the demonstration
23 project, promulgate rules concerning personal assistant
24 services, to include, but need not be limited to,
25 qualifications, employment screening, rights under fair labor
26 standards, training, fiduciary agent, and supervision
SB3365 Enrolled - 198 - LRB104 18483 SSS 31925 b
1 requirements. All applicants shall be subject to the
2 provisions of the Health Care Worker Background Check Act.
3 The Department shall develop procedures to enhance
4 availability of services on evenings, weekends, and on an
5 emergency basis to meet the respite needs of caregivers.
6 Procedures shall be developed to permit the utilization of
7 services in successive blocks of 24 hours up to the monthly
8 maximum established by the Department. Workers providing these
9 services shall be appropriately trained.
10 No person may perform chore/housekeeping and home care
11 aide services under a program authorized by this Section
12 unless that person has been issued a certificate of
13 pre-service to do so by his or her employing agency.
14 Information gathered to effect such certification shall
15 include (i) the person's name, (ii) the date the person was
16 hired by his or her current employer, and (iii) the training,
17 including dates and levels. Persons engaged in the program
18 authorized by this Section before the effective date of this
19 amendatory Act of 1991 shall be issued a certificate of all
20 pre-service and in-service training from his or her employer
21 upon submitting the necessary information. The employing
22 agency shall be required to retain records of all staff
23 pre-service and in-service training, and shall provide such
24 records to the Department upon request and upon termination of
25 the employer's contract with the Department. In addition, the
26 employing agency is responsible for the issuance of
SB3365 Enrolled - 199 - LRB104 18483 SSS 31925 b
1 certifications of in-service training completed to its their
2 employees.
3 The Department is required to develop a system to ensure
4 that persons working as home care aides and personal
5 assistants receive increases in their wages when the federal
6 minimum wage is increased by requiring vendors to certify that
7 they are meeting the federal minimum wage statute for home
8 care aides and personal assistants. An employer that cannot
9 ensure that the minimum wage increase is being given to home
10 care aides and personal assistants shall be denied any
11 increase in reimbursement costs.
12 The Community Care Program Advisory Committee is created
13 in the Department on Aging. The Director shall appoint
14 individuals to serve in the Committee, who shall serve at
15 their own expense. Members of the Committee must abide by all
16 applicable ethics laws. The Committee shall advise the
17 Department on issues related to the Department's program of
18 services to prevent unnecessary institutionalization. The
19 Committee shall meet on a bi-monthly basis and shall serve to
20 identify and advise the Department on present and potential
21 issues affecting the service delivery network, the program's
22 clients, and the Department and to recommend solution
23 strategies. Persons appointed to the Committee shall be
24 appointed on, but not limited to, their own and their agency's
25 experience with the program, geographic representation, and
26 willingness to serve. The Director shall appoint members to
SB3365 Enrolled - 200 - LRB104 18483 SSS 31925 b
1 the Committee to represent provider, advocacy, policy
2 research, and other constituencies committed to the delivery
3 of high quality home and community-based services to older
4 adults. Representatives shall be appointed to ensure
5 representation from community care providers, including, but
6 not limited to, adult day service providers, homemaker
7 providers, case coordination and case management units,
8 emergency home response providers, statewide trade or labor
9 unions that represent home care aides and direct care staff,
10 area agencies on aging, adults over age 60, membership
11 organizations representing older adults, and other
12 organizational entities, providers of care, or individuals
13 with demonstrated interest and expertise in the field of home
14 and community care as determined by the Director.
15 Nominations may be presented from any agency or State
16 association with interest in the program. The Director, or his
17 or her designee, shall serve as the permanent co-chair of the
18 advisory committee. One other co-chair shall be nominated and
19 approved by the members of the committee on an annual basis.
20 Committee members' terms of appointment shall be for 4 years
21 with one-quarter of the appointees' terms expiring each year.
22 A member shall continue to serve until his or her replacement
23 is named. The Department shall fill vacancies that have a
24 remaining term of over one year, and this replacement shall
25 occur through the annual replacement of expiring terms. The
26 Director shall designate Department staff to provide technical
SB3365 Enrolled - 201 - LRB104 18483 SSS 31925 b
1 assistance and staff support to the committee. Department
2 representation shall not constitute membership of the
3 committee. All Committee papers, issues, recommendations,
4 reports, and meeting memoranda are advisory only. The
5 Director, or his or her designee, shall make a written report,
6 as requested by the Committee, regarding issues before the
7 Committee.
8 The Department on Aging and the Department of Human
9 Services shall cooperate in the development and submission of
10 an annual report on programs and services provided under this
11 Section. Such joint report shall be filed with the Governor
12 and the General Assembly on or before March 31 of the following
13 fiscal year.
14 The requirement for reporting to the General Assembly
15 shall be satisfied by filing copies of the report as required
16 by Section 3.1 of the General Assembly Organization Act and
17 filing such additional copies with the State Government Report
18 Distribution Center for the General Assembly as is required
19 under paragraph (t) of Section 7 of the State Library Act.
20 Those persons previously found eligible for receiving
21 noninstitutional services whose services were discontinued
22 under the Emergency Budget Act of Fiscal Year 1992, and who do
23 not meet the eligibility standards in effect on or after July
24 1, 1992, shall remain ineligible on and after July 1, 1992.
25 Those persons previously not required to cost-share and who
26 were required to cost-share effective March 1, 1992, shall
SB3365 Enrolled - 202 - LRB104 18483 SSS 31925 b
1 continue to meet cost-share requirements on and after July 1,
2 1992. Beginning July 1, 1992, all clients will be required to
3 meet eligibility, cost-share, and other requirements and will
4 have services discontinued or altered when they fail to meet
5 these requirements.
6 For the purposes of this Section, "flexible senior
7 services" refers to services that require one-time or periodic
8 expenditures, including, but not limited to, respite care,
9 home modification, assistive technology, housing assistance,
10 and transportation.
11 The Department shall implement an electronic service
12 verification based on global positioning systems or other
13 cost-effective technology for the Community Care Program no
14 later than January 1, 2014.
15 The Department shall require, as a condition of
16 eligibility, application for the medical assistance program
17 under Article V of the Illinois Public Aid Code.
18 The Department may authorize Community Care Program
19 services until an applicant is determined eligible for medical
20 assistance under Article V of the Illinois Public Aid Code.
21 The Department shall continue to provide Community Care
22 Program reports as required by statute, which shall include an
23 annual report on Care Coordination Unit performance and
24 adherence to service guidelines and a 6-month supplemental
25 report.
26 In regard to community care providers, failure to comply
SB3365 Enrolled - 203 - LRB104 18483 SSS 31925 b
1 with Department on Aging policies shall be cause for
2 disciplinary action, including, but not limited to,
3 disqualification from serving Community Care Program clients.
4 Each provider, upon submission of any bill or invoice to the
5 Department for payment for services rendered, shall include a
6 notarized statement, under penalty of perjury pursuant to
7 Section 1-109 of the Code of Civil Procedure, that the
8 provider has complied with all Department policies.
9 The Director of the Department on Aging shall make
10 information available to the State Board of Elections as may
11 be required by an agreement the State Board of Elections has
12 entered into with a multi-state voter registration list
13 maintenance system.
14 The Department shall pay an enhanced rate of at least
15 $1.77 per unit under the Community Care Program to those
16 in-home service provider agencies that offer health insurance
17 coverage as a benefit to their direct service worker employees
18 pursuant to rules adopted by the Department. The Department
19 shall review the enhanced rate as part of its process to rebase
20 in-home service provider reimbursement rates pursuant to
21 federal waiver requirements. Subject to federal approval,
22 beginning on January 1, 2024, rates for adult day services
23 shall be increased to $16.84 per hour and rates for each way
24 transportation services for adult day services shall be
25 increased to $12.44 per unit transportation.
26 Subject to federal approval, on and after January 1, 2024,
SB3365 Enrolled - 204 - LRB104 18483 SSS 31925 b
1 rates for homemaker services shall be increased to $28.07 to
2 sustain a minimum wage of $17 per hour for direct service
3 workers. Rates in subsequent State fiscal years shall be no
4 lower than the rates put into effect upon federal approval.
5 Providers of in-home services shall be required to certify to
6 the Department that they remain in compliance with the
7 mandated wage increase for direct service workers. Fringe
8 benefits, including, but not limited to, paid time off and
9 payment for training, health insurance, travel, or
10 transportation, shall not be reduced in relation to the rate
11 increases described in this paragraph.
12 Subject to and upon federal approval, on and after January
13 1, 2025, rates for homemaker services shall be increased to
14 $29.63 to sustain a minimum wage of $18 per hour for direct
15 service workers. Rates in subsequent State fiscal years shall
16 be no lower than the rates put into effect upon federal
17 approval. Providers of in-home services shall be required to
18 certify to the Department that they remain in compliance with
19 the mandated wage increase for direct service workers. Fringe
20 benefits, including, but not limited to, paid time off and
21 payment for training, health insurance, travel, or
22 transportation, shall not be reduced in relation to the rate
23 increases described in this paragraph.
24 Subject to and upon federal approval, on and after January
25 1, 2026, rates for homemaker services shall be increased to
26 $30.80 to sustain a minimum wage of $18.75 per hour for direct
SB3365 Enrolled - 205 - LRB104 18483 SSS 31925 b
1 service workers. Rates in subsequent State fiscal years shall
2 be no lower than the rates put into effect upon federal
3 approval. Providers of in-home services shall be required to
4 certify to the Department that they remain in compliance with
5 the mandated wage increase for direct service workers. Fringe
6 benefits, including, but not limited to, paid time off and
7 payment for training, health insurance, travel, or
8 transportation, shall not be reduced in relation to the rate
9 increases described in this paragraph.
10 Beginning January 1, 2027, subject to any necessary
11 federal approval, rates for adult day services shall be
12 increased to $17.84 per hour and rates for each way
13 transportation services for adult day services shall be
14 increased to $13.44 per unit transportation.
15 The General Assembly finds it necessary to authorize an
16 aggressive Medicaid enrollment initiative designed to maximize
17 federal Medicaid funding for the Community Care Program which
18 produces significant savings for the State of Illinois. The
19 Department on Aging shall establish and implement a Community
20 Care Program Medicaid Initiative. Under the Initiative, the
21 Department on Aging shall, at a minimum: (i) provide an
22 enhanced rate to adequately compensate care coordination units
23 to enroll eligible Community Care Program clients into
24 Medicaid; (ii) use recommendations from a stakeholder
25 committee on how best to implement the Initiative; and (iii)
26 establish requirements for State agencies to make enrollment
SB3365 Enrolled - 206 - LRB104 18483 SSS 31925 b
1 in the State's Medical Assistance program easier for seniors.
2 The Community Care Program Medicaid Enrollment Oversight
3 Subcommittee is created as a subcommittee of the Older Adult
4 Services Advisory Committee established in Section 35 of the
5 Older Adult Services Act to make recommendations on how best
6 to increase the number of medical assistance recipients who
7 are enrolled in the Community Care Program. The Subcommittee
8 shall consist of all of the following persons who must be
9 appointed within 30 days after June 4, 2018 (the effective
10 date of Public Act 100-587):
11 (1) The Director of Aging, or his or her designee, who
12 shall serve as the chairperson of the Subcommittee.
13 (2) One representative of the Department of Healthcare
14 and Family Services, appointed by the Director of
15 Healthcare and Family Services.
16 (3) One representative of the Department of Human
17 Services, appointed by the Secretary of Human Services.
18 (4) One individual representing a care coordination
19 unit, appointed by the Director of Aging.
20 (5) One individual from a non-governmental statewide
21 organization that advocates for seniors, appointed by the
22 Director of Aging.
23 (6) One individual representing Area Agencies on
24 Aging, appointed by the Director of Aging.
25 (7) One individual from a statewide association
26 dedicated to Alzheimer's care, support, and research,
SB3365 Enrolled - 207 - LRB104 18483 SSS 31925 b
1 appointed by the Director of Aging.
2 (8) One individual from an organization that employs
3 persons who provide services under the Community Care
4 Program, appointed by the Director of Aging.
5 (9) One member of a trade or labor union representing
6 persons who provide services under the Community Care
7 Program, appointed by the Director of Aging.
8 (10) One member of the Senate, who shall serve as
9 co-chairperson, appointed by the President of the Senate.
10 (11) One member of the Senate, who shall serve as
11 co-chairperson, appointed by the Minority Leader of the
12 Senate.
13 (12) One member of the House of Representatives, who
14 shall serve as co-chairperson, appointed by the Speaker of
15 the House of Representatives.
16 (13) One member of the House of Representatives, who
17 shall serve as co-chairperson, appointed by the Minority
18 Leader of the House of Representatives.
19 (14) One individual appointed by a labor organization
20 representing frontline employees at the Department of
21 Human Services.
22 The Subcommittee shall provide oversight to the Community
23 Care Program Medicaid Initiative and shall meet quarterly. At
24 each Subcommittee meeting the Department on Aging shall
25 provide the following data sets to the Subcommittee: (A) the
26 number of Illinois residents, categorized by planning and
SB3365 Enrolled - 208 - LRB104 18483 SSS 31925 b
1 service area, who are receiving services under the Community
2 Care Program and are enrolled in the State's Medical
3 Assistance Program; (B) the number of Illinois residents,
4 categorized by planning and service area, who are receiving
5 services under the Community Care Program, but are not
6 enrolled in the State's Medical Assistance Program; and (C)
7 the number of Illinois residents, categorized by planning and
8 service area, who are receiving services under the Community
9 Care Program and are eligible for benefits under the State's
10 Medical Assistance Program, but are not enrolled in the
11 State's Medical Assistance Program. In addition to this data,
12 the Department on Aging shall provide the Subcommittee with
13 plans on how the Department on Aging will reduce the number of
14 Illinois residents who are not enrolled in the State's Medical
15 Assistance Program but who are eligible for medical assistance
16 benefits. The Department on Aging shall enroll in the State's
17 Medical Assistance Program those Illinois residents who
18 receive services under the Community Care Program and are
19 eligible for medical assistance benefits but are not enrolled
20 in the State's Medical Medicaid Assistance Program. The data
21 provided to the Subcommittee shall be made available to the
22 public via the Department on Aging's website.
23 The Department on Aging, with the involvement of the
24 Subcommittee, shall collaborate with the Department of Human
25 Services and the Department of Healthcare and Family Services
26 on how best to achieve the responsibilities of the Community
SB3365 Enrolled - 209 - LRB104 18483 SSS 31925 b
1 Care Program Medicaid Initiative.
2 The Department on Aging, the Department of Human Services,
3 and the Department of Healthcare and Family Services shall
4 coordinate and implement a streamlined process for seniors to
5 access benefits under the State's Medical Assistance Program.
6 The Subcommittee shall collaborate with the Department of
7 Human Services on the adoption of a uniform application
8 submission process. The Department of Human Services and any
9 other State agency involved with processing the medical
10 assistance application of any person enrolled in the Community
11 Care Program shall include the appropriate care coordination
12 unit in all communications related to the determination or
13 status of the application.
14 The Community Care Program Medicaid Initiative shall
15 provide targeted funding to care coordination units to help
16 seniors complete their applications for medical assistance
17 benefits. On and after July 1, 2019, care coordination units
18 shall receive no less than $200 per completed application,
19 which rate may be included in a bundled rate for initial intake
20 services when Medicaid application assistance is provided in
21 conjunction with the initial intake process for new program
22 participants.
23 The Community Care Program Medicaid Initiative shall cease
24 operation 5 years after June 4, 2018 (the effective date of
25 Public Act 100-587), after which the Subcommittee shall
26 dissolve.
SB3365 Enrolled - 210 - LRB104 18483 SSS 31925 b
1 Effective July 1, 2023, subject to federal approval, the
2 Department on Aging shall reimburse Care Coordination Units at
3 the following rates for case management services: $252.40 for
4 each initial assessment; $366.40 for each initial assessment
5 with translation; $229.68 for each redetermination assessment;
6 $313.68 for each redetermination assessment with translation;
7 $200.00 for each completed application for medical assistance
8 benefits; $132.26 for each face-to-face, choices-for-care
9 screening; $168.26 for each face-to-face, choices-for-care
10 screening with translation; $124.56 for each 6-month,
11 face-to-face visit; $132.00 for each MCO participant
12 eligibility determination; and $157.00 for each MCO
13 participant eligibility determination with translation.
14 (Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
15 45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
16 1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;
17 103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
18 1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)
19 ARTICLE 145.
20 Section 145-5. The Illinois Public Aid Code is amended by
21 changing Section 14-12.5 as follows:
22 (305 ILCS 5/14-12.5)
23 Sec. 14-12.5. Hospital rate updates.
SB3365 Enrolled - 211 - LRB104 18483 SSS 31925 b
1 (a) Notwithstanding any other provision of this Code, the
2 hospital rates of reimbursement authorized under Sections
3 5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
4 accordance with the provisions of this Section.
5 (b) Notwithstanding any other provision of this Code,
6 effective for dates of service on and after January 1, 2024,
7 subject to federal approval, hospital reimbursement rates
8 shall be revised as follows:
9 (1) For inpatient general acute care services, the
10 statewide-standardized amount and the per diem rates for
11 hospitals exempt from the APR-DRG reimbursement system, in
12 effect January 1, 2023, shall be increased by 10%.
13 (2) For inpatient psychiatric services:
14 (A) For safety-net hospitals, the hospital
15 specific per diem rate in effect January 1, 2023 and
16 the minimum per diem rate of $630, authorized in
17 subsection (b-5) of Section 5-5.05 of this Code, shall
18 be increased by 10%.
19 (B) For all general acute care hospitals that are
20 not safety-net hospitals, the inpatient psychiatric
21 care per diem rates in effect January 1, 2023 shall be
22 increased by 10%, except that all rates shall be at
23 least 90% of the minimum inpatient psychiatric care
24 per diem rate for safety-net hospitals as authorized
25 in subsection (b-5) of Section 5-5.05 of this Code
26 including the adjustments authorized in this Section.
SB3365 Enrolled - 212 - LRB104 18483 SSS 31925 b
1 The statewide default per diem rate for a hospital
2 opening a new psychiatric distinct part unit, shall be
3 set at 90% of the minimum inpatient psychiatric care
4 per diem rate for safety-net hospitals as authorized
5 in subsection (b-5) of Section 5-5.05 of this Code,
6 including the adjustment authorized in this Section.
7 (C) For all psychiatric specialty hospitals, the
8 per diem rates in effect January 1, 2023, shall be
9 increased by 10%, except that all rates shall be at
10 least 90% of the minimum inpatient per diem rate for
11 safety-net hospitals as authorized in subsection (b-5)
12 of Section 5-5.05 of this Code, including the
13 adjustments authorized in this Section. The statewide
14 default per diem rate for a new psychiatric specialty
15 hospital shall be set at 90% of the minimum inpatient
16 psychiatric care per diem rate for safety-net
17 hospitals as authorized in subsection (b-5) of Section
18 5-5.05 of this Code, including the adjustment
19 authorized in this Section.
20 (3) For inpatient rehabilitative services, all
21 hospital specific per diem rates in effect January 1,
22 2023, shall be increased by 10%. The statewide default
23 inpatient rehabilitative services per diem rates, for
24 general acute care hospitals and for rehabilitation
25 specialty hospitals respectively, shall be increased by
26 10%.
SB3365 Enrolled - 213 - LRB104 18483 SSS 31925 b
1 (4) The statewide-standardized amount for outpatient
2 general acute care services in effect January 1, 2023,
3 shall be increased by 10%.
4 (5) The statewide-standardized amount for outpatient
5 psychiatric care services in effect January 1, 2023, shall
6 be increased by 10%.
7 (6) The statewide-standardized amount for outpatient
8 rehabilitative care services in effect January 1, 2023,
9 shall be increased by 10%.
10 (7) The per diem rate in effect January 1, 2023, as
11 authorized in subsection (a) of Section 14-13 of this
12 Article shall be increased by 10%.
13 (8) For services provided on and after January 1, 2024
14 through June 30, 2024, and on and after January 1, 2029
15 2027, subject to federal approval, in addition to the
16 statewide standardized amount, an add-on payment of at
17 least $210 shall be paid for each inpatient General Acute
18 and Psychiatric day of care, excluding Medicare-Medicaid
19 dual eligible crossover days, for all safety-net hospitals
20 defined in Section 5-5e.1 of this Code.
21 (A) For Psychiatric days of care, the Department
22 may implement payment of this add-on by increasing the
23 hospital specific psychiatric per diem rate, adjusted
24 in accordance with subparagraph (A) of paragraph (2)
25 of subsection (b) by $210, or by a separate add-on
26 payment.
SB3365 Enrolled - 214 - LRB104 18483 SSS 31925 b
1 (B) If the add-on adjustment is added to the
2 hospital specific psychiatric per diem rate to
3 operationalize payment, the Department shall provide a
4 rate sheet to each safety-net hospital, which
5 identifies the hospital psychiatric per diem rate
6 before and after the adjustment.
7 (C) The add-on adjustment shall not be considered
8 when setting the 90% minimum rate identified in
9 paragraph (2) of subsection (b).
10 (9) For services provided on and after July 1, 2024,
11 and on or before December 31, 2028 2026, subject to
12 federal approval, in addition to the statewide
13 standardized amount and any other payments authorized
14 under this Code, a safety-net hospital health care equity
15 add-on payment shall be paid for each inpatient General
16 Acute and Psychiatric day of care, excluding
17 Medicare-Medicaid dual eligible crossover days, for
18 safety-net hospitals defined in Section 5-5e.1 of this
19 Code, as follows:
20 (A) if the safety-net hospital's Medicaid
21 inpatient utilization rate, as calculated under
22 Section 5-5e.1 of this Code, is equal to or greater
23 than 70%, the add-on payment shall be $425;
24 (B) if the safety-net hospital's Medicaid
25 inpatient utilization rate, as calculated under
26 Section 5-5e.1 of this Code, is equal to or greater
SB3365 Enrolled - 215 - LRB104 18483 SSS 31925 b
1 than 50% and less than 70%, the add-on payment shall be
2 $300;
3 (C) if the safety-net hospital's Medicaid
4 inpatient utilization rate, as calculated under
5 Section 5-5e.1 of this Code, is equal to or greater
6 than 40% and less than 50%, the add-on payment shall be
7 $225; and
8 (D) if the safety-net hospital's Medicaid
9 inpatient utilization rate, as calculated under
10 Section 5-5e.1 of this Code, is less than 40%, the
11 add-on payment shall be $210.
12 Qualification for the safety-net hospital health care
13 equity add-on payment shall be updated January 1, 2026,
14 and each January 1 thereafter based on the MIUR
15 determination effective 3 months prior to the start of
16 each the January 1, 2026 calendar year, ending in 2028.
17 Rates described in subparagraphs (A) through (C) shall
18 be adjusted annually beginning January 1, 2026 by applying
19 a uniform factor to each rate to spend an approximate
20 amount of $50,000,000 annually per year using State fiscal
21 year 2024 days as a basis for calendar year 2026 rates.
22 The add-on adjustment under this paragraph shall not
23 be considered when setting the 90% minimum rate identified
24 in subparagraph (B) of paragraph (2).
25 (10) For services provided on and after July 1, 2024,
26 and on or before December 31, 2028 2026, subject to
SB3365 Enrolled - 216 - LRB104 18483 SSS 31925 b
1 federal approval, in addition to the statewide
2 standardized amount and any other payments authorized
3 under this Code, a safety-net hospital low volume add-on
4 payment of the lesser of $200 or the annually recalculated
5 amount described below shall be paid for each inpatient
6 General Acute and Psychiatric day of care, excluding
7 Medicare-Medicaid dual eligible crossover days, for any
8 safety-net hospital as defined in Section 5-5e.1 that
9 provided less than 11,000 Medicaid inpatient days of care,
10 excluding Medicare-Medicaid dual eligible crossover days,
11 in the base period. As used in this paragraph, "base
12 period" means State fiscal year 2022 admissions received
13 by the Department prior to October 1, 2023 for the payment
14 period July 1, 2024 through December 31, 2025, and
15 beginning in calendar year 2026, the State fiscal year
16 that ends 30 months before the applicable calendar year,
17 such as State fiscal year 2023 admissions received by the
18 Department prior to October 1, 2024, for calendar year
19 2026. The low volume add-on payment amount of $200 shall
20 be adjusted annually beginning January 1, 2027 if
21 projected overall payment exceeds $30,000,000 by setting a
22 rate to spend an approximate amount of $30,000,000
23 annually using the most recent complete State fiscal year
24 inpatient General Acute and Psychiatric day of care data,
25 excluding Medicare-Medicaid dual eligible crossover days
26 for qualifying hospitals. State Fiscal Year 2025 data
SB3365 Enrolled - 217 - LRB104 18483 SSS 31925 b
1 shall be used as the basis for the Calendar Year 2027 rate,
2 and State Fiscal Year 2026 data shall be used as the basis
3 for the Calendar Year 2028 rate.
4 (c) The Department shall take all actions necessary to
5 ensure the changes authorized in Public Act 103-102 and this
6 amendatory Act of the 103rd General Assembly are in effect for
7 dates of service on and after the effective date of the changes
8 made to this Section by this amendatory Act of the 103rd
9 General Assembly, including publishing all appropriate public
10 notices, applying for federal approval of amendments to the
11 Illinois Title XIX State Plan, and adopting administrative
12 rules if necessary.
13 (d) The Department of Healthcare and Family Services may
14 adopt rules necessary to implement the changes made by Public
15 Act 103-102 and this amendatory Act of the 103rd General
16 Assembly through the use of emergency rulemaking in accordance
17 with Section 5-45 of the Illinois Administrative Procedure
18 Act. The 24-month limitation on the adoption of emergency
19 rules does not apply to rules adopted under this Section. The
20 General Assembly finds that the adoption of rules to implement
21 the changes made by Public Act 103-102 and this amendatory Act
22 of the 103rd General Assembly is deemed an emergency and
23 necessary for the public interest, safety, and welfare.
24 (e) The Department shall ensure that all necessary
25 adjustments to the managed care organization capitation base
26 rates necessitated by the adjustments in this Section are
SB3365 Enrolled - 218 - LRB104 18483 SSS 31925 b
1 completed, published, and applied in accordance with Section
2 5-30.8 of this Code 90 days prior to the implementation date of
3 the changes required under Public Act 103-102 and this
4 amendatory Act of the 103rd General Assembly.
5 (f) The Department shall publish updated rate sheets or
6 add-on payment amounts, as applicable, for all hospitals 30
7 days prior to the effective date of the rate increase, or
8 within 30 days after federal approval by the Centers for
9 Medicare and Medicaid Services, whichever is later.
10 (Source: P.A. 103-102, eff. 6-16-23; 103-593, eff. 6-7-24.)
11 ARTICLE 175.
12 Section 175-5. The Illinois Public Aid Code is amended by
13 changing Section 5-30.1 as follows:
14 (305 ILCS 5/5-30.1)
15 Sec. 5-30.1. Managed care protections.
16 (a) As used in this Section:
17 "Managed care organization" or "MCO" means any entity
18 which contracts with the Department to provide services where
19 payment for medical services is made on a capitated basis.
20 "Emergency services" means health care items and services,
21 including inpatient and outpatient hospital services,
22 furnished or required to evaluate and stabilize an emergency
23 medical condition. "Emergency services" include inpatient
SB3365 Enrolled - 219 - LRB104 18483 SSS 31925 b
1 stabilization services furnished during the inpatient
2 stabilization period. "Emergency services" do not include
3 post-stabilization medical services.
4 "Emergency medical condition" means a medical condition
5 manifesting itself by acute symptoms of sufficient severity,
6 regardless of the final diagnosis given, such that a prudent
7 layperson, who possesses an average knowledge of health and
8 medicine, could reasonably expect the absence of immediate
9 medical attention to result in:
10 (1) placing the health of the individual (or, with
11 respect to a pregnant woman, the health of the woman or her
12 unborn child) in serious jeopardy;
13 (2) serious impairment to bodily functions;
14 (3) serious dysfunction of any bodily organ or part;
15 (4) inadequately controlled pain; or
16 (5) with respect to a pregnant woman who is having
17 contractions:
18 (A) inadequate time to complete a safe transfer to
19 another hospital before delivery; or
20 (B) a transfer to another hospital may pose a
21 threat to the health or safety of the woman or unborn
22 child.
23 "Emergency medical screening examination" means a medical
24 screening examination and evaluation by a physician licensed
25 to practice medicine in all its branches or, to the extent
26 permitted by applicable laws, by other appropriately licensed
SB3365 Enrolled - 220 - LRB104 18483 SSS 31925 b
1 personnel under the supervision of or in collaboration with a
2 physician licensed to practice medicine in all its branches to
3 determine whether the need for emergency services exists.
4 "Health care services" means mean any medical or
5 behavioral health services covered under the medical
6 assistance program that are subject to review under a service
7 authorization program.
8 "Inpatient stabilization period" means the initial 72
9 hours of inpatient stabilization services, beginning from the
10 date and time of the order for inpatient admission to the
11 hospital.
12 "Inpatient stabilization services" means mean emergency
13 services furnished in the inpatient setting at a hospital
14 pursuant to an order for inpatient admission by a physician or
15 other qualified practitioner who has admitting privileges at
16 the hospital, as permitted by State law, to stabilize an
17 emergency medical condition following an emergency medical
18 screening examination.
19 "Post-stabilization medical services" means health care
20 services provided to an enrollee that are furnished in a
21 hospital by a provider that is qualified to furnish such
22 services and determined to be medically necessary by the
23 provider and directly related to the emergency medical
24 condition following stabilization.
25 "Provider" means a facility or individual who is actively
26 enrolled in the medical assistance program and licensed or
SB3365 Enrolled - 221 - LRB104 18483 SSS 31925 b
1 otherwise authorized to order, prescribe, refer, or render
2 health care services in this State.
3 "Service authorization determination" means a decision
4 made by a service authorization program in advance of,
5 concurrent to, or after the provision of a health care service
6 to approve, change the level of care, partially deny, deny, or
7 otherwise limit coverage and reimbursement for a health care
8 service upon review of a service authorization request.
9 "Service authorization program" means any utilization
10 review, utilization management, peer review, quality review,
11 or other medical management activity conducted by an MCO, or
12 its contracted utilization review organization, including, but
13 not limited to, prior authorization, prior approval,
14 pre-certification, concurrent review, retrospective review, or
15 certification of admission, of health care services provided
16 in the inpatient or outpatient hospital setting.
17 "Service authorization request" means a request by a
18 provider to a service authorization program to determine
19 whether a health care service meets the reimbursement
20 eligibility requirements for medically necessary, clinically
21 appropriate care, resulting in the issuance of a service
22 authorization determination.
23 "Utilization review organization" or "URO" means an MCO's
24 utilization review department or a peer review organization or
25 quality improvement organization that contracts with an MCO to
26 administer a service authorization program and make service
SB3365 Enrolled - 222 - LRB104 18483 SSS 31925 b
1 authorization determinations.
2 (b) As provided by Section 5-16.12, managed care
3 organizations are subject to the provisions of the Managed
4 Care Reform and Patient Rights Act.
5 (c) An MCO shall pay any provider of emergency services,
6 including for inpatient stabilization services provided during
7 the inpatient stabilization period, that does not have in
8 effect a contract with the contracted Medicaid MCO. The
9 default rate of reimbursement shall be the rate paid under
10 Illinois Medicaid fee-for-service program methodology,
11 including all policy adjusters, including but not limited to
12 Medicaid High Volume Adjustments, Medicaid Percentage
13 Adjustments, Outpatient High Volume Adjustments, and all
14 outlier add-on adjustments to the extent such adjustments are
15 incorporated in the development of the applicable MCO
16 capitated rates.
17 (d) (Blank).
18 (e) Notwithstanding any other provision of law, the
19 following requirements apply to MCOs in determining payment
20 for all emergency services, including inpatient stabilization
21 services provided during the inpatient stabilization period:
22 (1) The MCO shall not impose any service authorization
23 program requirements for emergency services, including,
24 but not limited to, prior authorization, prior approval,
25 pre-certification, certification of admission, concurrent
26 review, or retrospective review.
SB3365 Enrolled - 223 - LRB104 18483 SSS 31925 b
1 (A) Notification period: Hospitals shall notify
2 the enrollee's Medicaid MCO within 48 hours of the
3 date and time the order for inpatient admission is
4 written. Notification shall be limited to advising the
5 MCO that the patient has been admitted to a hospital
6 inpatient level of care.
7 (B) If the admitting hospital complies with the
8 notification provisions of subparagraph (A), the
9 Medicaid MCO may not initiate concurrent review before
10 the end of the inpatient stabilization period. If the
11 admitting hospital does not comply with the
12 notification requirements in subparagraph (A), the
13 Medicaid MCO may initiate concurrent review for the
14 continuation of the stay beginning at the end of the
15 48-hour notification period.
16 (C) Coverage for services provided during the
17 48-hour notification period may not be retrospectively
18 denied.
19 (2) The MCO shall cover emergency services provided to
20 enrollees who are temporarily away from their residence
21 and outside the contracting area to the extent that the
22 enrollees would be entitled to the emergency services if
23 they still were within the contracting area.
24 (3) The MCO shall have no obligation to cover
25 emergency services provided on an emergency basis that are
26 not covered services under the contract between the MCO
SB3365 Enrolled - 224 - LRB104 18483 SSS 31925 b
1 and the Department.
2 (4) The MCO shall not condition coverage for emergency
3 services on the treating provider notifying the MCO of the
4 enrollee's emergency medical screening examination and
5 treatment within 10 days after presentation for emergency
6 services.
7 (5) The determination of the attending emergency
8 physician, or the practitioner responsible for the
9 enrollee's care at the hospital, of whether an enrollee
10 requires inpatient stabilization services, can be
11 stabilized in the outpatient setting, or is sufficiently
12 stabilized for discharge or transfer to another setting,
13 shall be binding on the MCO. The MCO shall cover and
14 reimburse providers for emergency services as billed by
15 the provider for all enrollees whether the emergency
16 services are provided by an affiliated or non-affiliated
17 provider, except in cases of fraud. The MCO shall
18 reimburse inpatient stabilization services provided during
19 the inpatient stabilization period and billed as inpatient
20 level of care based on the appropriate inpatient
21 reimbursement methodology.
22 (6) The MCO's financial responsibility for
23 post-stabilization medical services it has not
24 pre-approved ends when:
25 (A) a plan physician with privileges at the
26 treating hospital assumes responsibility for the
SB3365 Enrolled - 225 - LRB104 18483 SSS 31925 b
1 enrollee's care;
2 (B) a plan physician assumes responsibility for
3 the enrollee's care through transfer;
4 (C) a contracting entity representative and the
5 treating physician reach an agreement concerning the
6 enrollee's care; or
7 (D) the enrollee is discharged.
8 (e-5) An MCO shall pay for all post-stabilization medical
9 services as a covered service in any of the following
10 situations:
11 (1) the MCO or its URO authorized such services;
12 (2) such services were administered to maintain the
13 enrollee's stabilized condition within one hour after a
14 request to the MCO for authorization of further
15 post-stabilization services;
16 (3) the MCO or its URO did not respond to a request to
17 authorize such services within one hour;
18 (4) the MCO or its URO could not be contacted; or
19 (5) the MCO or its URO and the treating provider, if
20 the treating provider is a non-affiliated provider, could
21 not reach an agreement concerning the enrollee's care and
22 an affiliated provider was unavailable for a consultation,
23 in which case the MCO must pay for such services rendered
24 by the treating non-affiliated provider until an
25 affiliated provider was reached and either concurred with
26 the treating non-affiliated provider's plan of care or
SB3365 Enrolled - 226 - LRB104 18483 SSS 31925 b
1 assumed responsibility for the enrollee's care. Such
2 payment shall be made at the default rate of reimbursement
3 paid under the State's Medicaid fee-for-service program
4 methodology, including all policy adjusters, including,
5 but not limited to, Medicaid High Volume Adjustments,
6 Medicaid Percentage Adjustments, Outpatient High Volume
7 Adjustments, and all outlier add-on adjustments to the
8 extent that such adjustments are incorporated in the
9 development of the applicable MCO capitated rates.
10 (f) Network adequacy and transparency.
11 (1) The Department shall:
12 (A) ensure that an adequate provider network is in
13 place, taking into consideration health professional
14 shortage areas and medically underserved areas;
15 (B) publicly release an explanation of its process
16 for analyzing network adequacy;
17 (C) periodically ensure that an MCO continues to
18 have an adequate network in place;
19 (D) require MCOs, including Medicaid Managed Care
20 Entities as defined in Section 5-30.2, to meet
21 provider directory requirements under Section 5-30.3;
22 (E) require MCOs to ensure that any
23 Medicaid-certified provider under contract with an MCO
24 and previously submitted on a roster on the date of
25 service is paid for any medically necessary,
26 Medicaid-covered, and authorized service rendered to
SB3365 Enrolled - 227 - LRB104 18483 SSS 31925 b
1 any of the MCO's enrollees, regardless of inclusion on
2 the MCO's published and publicly available directory
3 of available providers; and
4 (F) require MCOs, including Medicaid Managed Care
5 Entities as defined in Section 5-30.2, to meet each of
6 the requirements under subsection (d-5) of Section 10
7 of the Network Adequacy and Transparency Act; with
8 necessary exceptions to the MCO's network to ensure
9 that admission and treatment with a provider or at a
10 treatment facility in accordance with the network
11 adequacy standards in paragraph (3) of subsection
12 (d-5) of Section 10 of the Network Adequacy and
13 Transparency Act is limited to providers or facilities
14 that are Medicaid certified.
15 (2) Each MCO shall confirm its receipt of information
16 submitted specific to physician or dentist additions or
17 physician or dentist deletions from the MCO's provider
18 network within 3 days after receiving all required
19 information from contracted physicians or dentists, and
20 electronic physician and dental directories must be
21 updated consistent with current rules as published by the
22 Centers for Medicare and Medicaid Services or its
23 successor agency.
24 (g) Timely payment of claims.
25 (1) The MCO shall pay a claim within 30 days of
26 receiving a claim that contains all the essential
SB3365 Enrolled - 228 - LRB104 18483 SSS 31925 b
1 information needed to adjudicate the claim.
2 (2) The MCO shall notify the billing party of its
3 inability to adjudicate a claim within 30 days of
4 receiving that claim.
5 (3) The MCO shall pay a penalty that is at least equal
6 to the timely payment interest penalty imposed under
7 Section 368a of the Illinois Insurance Code for any claims
8 not timely paid.
9 (A) When an MCO is required to pay a timely payment
10 interest penalty to a provider, the MCO must calculate
11 and pay the timely payment interest penalty that is
12 due to the provider within 30 days after the payment of
13 the claim. In no event shall a provider be required to
14 request or apply for payment of any owed timely
15 payment interest penalties.
16 (B) Such payments shall be reported separately
17 from the claim payment for services rendered to the
18 MCO's enrollee and clearly identified as interest
19 payments.
20 (4)(A) The Department shall require MCOs to expedite
21 payments to providers identified on the Department's
22 expedited provider list, determined in accordance with 89
23 Ill. Adm. Code 140.71(b), on a schedule at least as
24 frequently as the providers are paid under the
25 Department's fee-for-service expedited provider schedule.
26 (B) Compliance with the expedited provider requirement
SB3365 Enrolled - 229 - LRB104 18483 SSS 31925 b
1 may be satisfied by an MCO through the use of a Periodic
2 Interim Payment (PIP) program that has been mutually
3 agreed to and documented between the MCO and the provider,
4 if the PIP program ensures that any expedited provider
5 receives regular and periodic payments based on prior
6 period payment experience from that MCO. Total payments
7 under the PIP program may be reconciled against future PIP
8 payments on a schedule mutually agreed to between the MCO
9 and the provider.
10 (C) The Department shall share at least monthly its
11 expedited provider list and the frequency with which it
12 pays providers on the expedited list.
13 (g-5) Recognizing that the rapid transformation of the
14 Illinois Medicaid program may have unintended operational
15 challenges for both payers and providers:
16 (1) in no instance shall a medically necessary covered
17 service rendered in good faith, based upon eligibility
18 information documented by the provider, be denied coverage
19 or diminished in payment amount if the eligibility or
20 coverage information available at the time the service was
21 rendered is later found to be inaccurate in the assignment
22 of coverage responsibility between MCOs or the
23 fee-for-service system, except for instances when an
24 individual is deemed to have not been eligible for
25 coverage under the Illinois Medicaid program; and
26 (2) the Department shall, by December 31, 2016, adopt
SB3365 Enrolled - 230 - LRB104 18483 SSS 31925 b
1 rules establishing policies that shall be included in the
2 Medicaid managed care policy and procedures manual
3 addressing payment resolutions in situations in which a
4 provider renders services based upon information obtained
5 after verifying a patient's eligibility and coverage plan
6 through either the Department's current enrollment system
7 or a system operated by the coverage plan identified by
8 the patient presenting for services:
9 (A) such medically necessary covered services
10 shall be considered rendered in good faith;
11 (B) such policies and procedures shall be
12 developed in consultation with industry
13 representatives of the Medicaid managed care health
14 plans and representatives of provider associations
15 representing the majority of providers within the
16 identified provider industry; and
17 (C) such rules shall be published for a review and
18 comment period of no less than 30 days on the
19 Department's website with final rules remaining
20 available on the Department's website.
21 The rules on payment resolutions shall include, but
22 not be limited to:
23 (A) the extension of the timely filing period;
24 (B) retroactive prior authorizations; and
25 (C) guaranteed minimum payment rate of no less
26 than the current, as of the date of service,
SB3365 Enrolled - 231 - LRB104 18483 SSS 31925 b
1 fee-for-service rate, plus all applicable add-ons,
2 when the resulting service relationship is out of
3 network.
4 The rules shall be applicable for both MCO coverage
5 and fee-for-service coverage.
6 If the fee-for-service system is ultimately determined to
7 have been responsible for coverage on the date of service, the
8 Department shall provide for an extended period for claims
9 submission outside the standard timely filing requirements.
10 (g-6) MCO Performance Metrics Report.
11 (1) The Department shall publish, on at least a
12 quarterly basis, each MCO's operational performance,
13 including, but not limited to, the following categories of
14 metrics:
15 (A) claims payment, including timeliness and
16 accuracy;
17 (B) prior authorizations;
18 (C) grievance and appeals;
19 (D) utilization statistics;
20 (E) provider disputes;
21 (F) provider credentialing; and
22 (G) member and provider customer service.
23 (2) The Department shall ensure that the metrics
24 report is accessible to providers online by January 1,
25 2017.
26 (3) The metrics shall be developed in consultation
SB3365 Enrolled - 232 - LRB104 18483 SSS 31925 b
1 with industry representatives of the Medicaid managed care
2 health plans and representatives of associations
3 representing the majority of providers within the
4 identified industry.
5 (4) Metrics shall be defined and incorporated into the
6 applicable Managed Care Policy Manual issued by the
7 Department.
8 (g-7) MCO claims processing and performance analysis. In
9 order to monitor MCO payments to hospital providers, pursuant
10 to Public Act 100-580, the Department shall post an analysis
11 of MCO claims processing and payment performance on its
12 website every 6 months. Such analysis shall include a review
13 and evaluation of a representative sample of hospital claims
14 that are rejected and denied for clean and unclean claims and
15 the top 5 reasons for such actions and timeliness of claims
16 adjudication, which identifies the percentage of claims
17 adjudicated within 30, 60, 90, and over 90 days, and the dollar
18 amounts associated with those claims.
19 (g-8) Dispute resolution process. The Department shall
20 maintain a provider complaint portal through which a provider
21 can submit to the Department unresolved disputes with an MCO.
22 An unresolved dispute means an MCO's decision that denies in
23 whole or in part a claim for reimbursement to a provider for
24 health care services rendered by the provider to an enrollee
25 of the MCO with which the provider disagrees. Disputes shall
26 not be submitted to the portal until the provider has availed
SB3365 Enrolled - 233 - LRB104 18483 SSS 31925 b
1 itself of the MCO's internal dispute resolution process.
2 Disputes that are submitted to the MCO internal dispute
3 resolution process may be submitted to the Department of
4 Healthcare and Family Services' complaint portal no sooner
5 than 30 days after submitting to the MCO's internal process
6 and not later than 30 days after the unsatisfactory resolution
7 of the internal MCO process or 60 days after submitting the
8 dispute to the MCO internal process. Multiple claim disputes
9 involving the same MCO may be submitted in one complaint,
10 regardless of whether the claims are for different enrollees,
11 when the specific reason for non-payment of the claims
12 involves a common question of fact or policy. Within 10
13 business days of receipt of a complaint, the Department shall
14 present such disputes to the appropriate MCO, which shall then
15 have 30 days to issue its written proposal to resolve the
16 dispute. The Department may grant one 30-day extension of this
17 time frame to one of the parties to resolve the dispute. If the
18 dispute remains unresolved at the end of this time frame or the
19 provider is not satisfied with the MCO's written proposal to
20 resolve the dispute, the provider may, within 30 days, request
21 the Department to review the dispute and make a final
22 determination. Within 30 days of the request for Department
23 review of the dispute, both the provider and the MCO shall
24 present all relevant information to the Department for
25 resolution and make individuals with knowledge of the issues
26 available to the Department for further inquiry if needed.
SB3365 Enrolled - 234 - LRB104 18483 SSS 31925 b
1 Within 30 days of receiving the relevant information on the
2 dispute, or the lapse of the period for submitting such
3 information, the Department shall issue a written decision on
4 the dispute based on contractual terms between the provider
5 and the MCO, contractual terms between the MCO and the
6 Department of Healthcare and Family Services and applicable
7 Medicaid policy. The decision of the Department shall be
8 final. By January 1, 2020, the Department shall establish by
9 rule further details of this dispute resolution process.
10 Disputes between MCOs and providers presented to the
11 Department for resolution are not contested cases, as defined
12 in Section 1-30 of the Illinois Administrative Procedure Act,
13 conferring any right to an administrative hearing.
14 (g-9)(1) The Department shall publish annually on its
15 website a report on the calculation of each managed care
16 organization's medical loss ratio showing the following:
17 (A) Premium revenue, with appropriate adjustments.
18 (B) Benefit expense, setting forth the aggregate
19 amount spent for the following:
20 (i) Direct paid claims.
21 (ii) Subcapitation payments.
22 (iii) Other claim payments.
23 (iv) Direct reserves.
24 (v) Gross recoveries.
25 (vi) Expenses for activities that improve health
26 care quality as allowed by the Department.
SB3365 Enrolled - 235 - LRB104 18483 SSS 31925 b
1 (2) The medical loss ratio shall be calculated consistent
2 with federal law and regulation following a claims runout
3 period determined by the Department.
4 (g-10)(1) "Liability effective date" means the date on
5 which an MCO becomes responsible for payment for medically
6 necessary and covered services rendered by a provider to one
7 of its enrollees in accordance with the contract terms between
8 the MCO and the provider. The liability effective date shall
9 be the later of:
10 (A) The execution date of a network participation
11 contract agreement.
12 (B) The date the provider or its representative
13 submits to the MCO the complete and accurate standardized
14 roster form for the provider in the format approved by the
15 Department.
16 (C) The provider effective date contained within the
17 Department's provider enrollment subsystem within the
18 Illinois Medicaid Program Advanced Cloud Technology
19 (IMPACT) System.
20 (2) The standardized roster form may be submitted to the
21 MCO at the same time that the provider submits an enrollment
22 application to the Department through IMPACT.
23 (3) By October 1, 2019, the Department shall require all
24 MCOs to update their provider directory with information for
25 new practitioners of existing contracted providers within 30
26 days of receipt of a complete and accurate standardized roster
SB3365 Enrolled - 236 - LRB104 18483 SSS 31925 b
1 template in the format approved by the Department provided
2 that the provider is effective in the Department's provider
3 enrollment subsystem within the IMPACT system. Such provider
4 directory shall be readily accessible for purposes of
5 selecting an approved health care provider and comply with all
6 other federal and State requirements.
7 (g-11) The Department shall work with relevant
8 stakeholders on the development of operational guidelines to
9 enhance and improve operational performance of Illinois'
10 Medicaid managed care program, including, but not limited to,
11 improving provider billing practices, reducing claim
12 rejections and inappropriate payment denials, and
13 standardizing processes, procedures, definitions, and response
14 timelines, with the goal of reducing provider and MCO
15 administrative burdens and conflict. The Department shall
16 include a report on the progress of these program improvements
17 and other topics in its Fiscal Year 2020 annual report to the
18 General Assembly.
19 (g-12) Notwithstanding any other provision of law, if the
20 Department or an MCO requires submission of a claim for
21 payment in a non-electronic format, a provider shall always be
22 afforded a period of no less than 90 business days, as a
23 correction period, following any notification of rejection by
24 either the Department or the MCO to correct errors or
25 omissions in the original submission.
26 Under no circumstances, either by an MCO or under the
SB3365 Enrolled - 237 - LRB104 18483 SSS 31925 b
1 State's fee-for-service system, shall a provider be denied
2 payment for failure to comply with any timely submission
3 requirements under this Code or under any existing contract,
4 unless the non-electronic format claim submission occurs after
5 the initial 180 days following the latest date of service on
6 the claim, or after the 90 business days correction period
7 following notification to the provider of rejection or denial
8 of payment.
9 (g-13) Utilization Review Standardization and
10 Transparency.
11 (1) To ensure greater standardization and transparency
12 related to service authorization determinations, for all
13 individuals covered under the medical assistance program
14 and enrolled in the managed care program , including both
15 the fee-for-service and managed care programs, the
16 Department shall, in consultation with the MCOs, a
17 statewide association representing the MCOs, a statewide
18 association representing the majority of Illinois
19 hospitals, a statewide association representing
20 physicians, or any other interested parties deemed
21 appropriate by the Department, adopt administrative rules
22 consistent with this subsection, in accordance with the
23 Illinois Administrative Procedure Act.
24 (2) No later than July 1, 2025, the Department shall
25 in accordance with the Illinois Administrative Procedure
26 Act file emergency rules, and adopt permanent rules no
SB3365 Enrolled - 238 - LRB104 18483 SSS 31925 b
1 later than November 28, 2025 October 1, 2025, which govern
2 MCO practices for dates of services on and after July 1,
3 2025, as follows:
4 (A) guidelines related to the publication of MCO
5 service authorization policies;
6 (B) procedures listed on the Medicare Inpatient
7 Only list published on January 1, 2025 by the Centers
8 for Medicare and Medicaid Services in Addendum B to
9 CMS-1809-FC that, due to medical complexity, must be
10 reimbursed under the applicable inpatient methodology,
11 when provided in the inpatient setting and billed as
12 an inpatient service;
13 (C) standardization of administrative forms used
14 in the member appeal process;
15 (D) limitations on second or subsequent medical
16 necessity review of a health care service already
17 authorized by the MCO or URO under a service
18 authorization program;
19 (E) standardization of peer-to-peer processes and
20 timelines;
21 (F) defined criteria for urgent and standard
22 post-acute care and long-term acute care service
23 authorization requests; and
24 (G) standardized criteria for service
25 authorization programs for authorization of admission
26 to a long-term acute care hospital.
SB3365 Enrolled - 239 - LRB104 18483 SSS 31925 b
1 (3) The Department shall expand the scope of the
2 quality and compliance audits conducted by its contracted
3 external quality review organization to include, but not
4 be limited to:
5 (A) an analysis of the Medicaid MCO's compliance
6 with nationally recognized clinical decision
7 guidelines for inpatient and outpatient hospital
8 services;
9 (B) an analysis that compares and contrasts the
10 Medicaid MCO's service authorization determination
11 outcomes for inpatient and outpatient hospital
12 services to the outcomes of each other MCO plan and the
13 State's fee-for-service program model to evaluate
14 whether service authorization determinations are being
15 made consistently by all Medicaid MCOs to ensure that
16 all individuals are being treated in accordance with
17 equitable standards of care;
18 (C) an analysis, for each Medicaid MCO, of the
19 number of service authorization requests, including
20 requests for concurrent review of inpatient hospital
21 admissions and certification of inpatient hospital
22 admissions, received, initially denied, overturned
23 through any post-denial process including, but not
24 limited to, enrollee or provider appeal, peer-to-peer
25 review, or the provider dispute resolution process,
26 denied but approved for a lower or different level of
SB3365 Enrolled - 240 - LRB104 18483 SSS 31925 b
1 care, and the number denied on final determination;
2 and
3 (D) provide a written report to the General
4 Assembly, detailing the items listed in this
5 subsection and any other metrics deemed necessary by
6 the Department, by the second April, following June 7,
7 2025 2024 (the effective date of Public Act 103-593),
8 and each April thereafter. The Department shall make
9 this report available within 30 days of delivery to
10 the General Assembly, on its public facing website.
11 (h) The Department shall not expand mandatory MCO
12 enrollment into new counties beyond those counties already
13 designated by the Department as of June 1, 2014 for the
14 individuals whose eligibility for medical assistance is not
15 the seniors or people with disabilities population until the
16 Department provides an opportunity for accountable care
17 entities and MCOs to participate in such newly designated
18 counties.
19 (h-5) Leading indicator data sharing. By January 1, 2024,
20 the Department shall obtain input from the Department of Human
21 Services, the Department of Juvenile Justice, the Department
22 of Children and Family Services, the State Board of Education,
23 managed care organizations, providers, and clinical experts to
24 identify and analyze key indicators and data elements that can
25 be used in an analysis of lead indicators from assessments and
26 data sets available to the Department that can be shared with
SB3365 Enrolled - 241 - LRB104 18483 SSS 31925 b
1 managed care organizations and similar care coordination
2 entities contracted with the Department as leading indicators
3 for elevated behavioral health crisis risk for children,
4 including data sets such as the Illinois Medicaid
5 Comprehensive Assessment of Needs and Strengths (IM-CANS),
6 calls made to the State's Crisis and Referral Entry Services
7 (CARES) hotline, health services information from Health and
8 Human Services Innovators, or other data sets that may include
9 key indicators. The workgroup shall complete its
10 recommendations for leading indicator data elements on or
11 before September 1, 2024. To the extent permitted by State and
12 federal law, the identified leading indicators shall be shared
13 with managed care organizations and similar care coordination
14 entities contracted with the Department on or before December
15 1, 2024 for the purpose of improving care coordination with
16 the early detection of elevated risk. Leading indicators shall
17 be reassessed annually with stakeholder input. The Department
18 shall implement guidance to managed care organizations and
19 similar care coordination entities contracted with the
20 Department, so that the managed care organizations and care
21 coordination entities respond to lead indicators with services
22 and interventions that are designed to help stabilize the
23 child.
24 (i) The requirements of this Section apply to contracts
25 with accountable care entities and MCOs entered into, amended,
26 or renewed after June 16, 2014 (the effective date of Public
SB3365 Enrolled - 242 - LRB104 18483 SSS 31925 b
1 Act 98-651).
2 (j) Health care information released to managed care
3 organizations. A health care provider shall release to a
4 Medicaid managed care organization, upon request, and subject
5 to the Health Insurance Portability and Accountability Act of
6 1996 and any other law applicable to the release of health
7 information, the health care information of the MCO's
8 enrollee, if the enrollee has completed and signed a general
9 release form that grants to the health care provider
10 permission to release the recipient's health care information
11 to the recipient's insurance carrier.
12 (k) The Department of Healthcare and Family Services,
13 managed care organizations, a statewide organization
14 representing hospitals, and a statewide organization
15 representing safety-net hospitals shall explore ways to
16 support billing departments in safety-net hospitals.
17 (l) The requirements of this Section added by Public Act
18 102-4 shall apply to services provided on or after the first
19 day of the month that begins 60 days after April 27, 2021 (the
20 effective date of Public Act 102-4).
21 (m) Except where otherwise expressly specified, the
22 requirements of this Section added by Public Act 103-593 shall
23 apply to services provided on and after July 1, 2026.
24 (Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
25 103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
26 8-15-25.)
SB3365 Enrolled - 243 - LRB104 18483 SSS 31925 b
1 ARTICLE 180.
2 Section 180-5. The Psychiatric Residential Treatment
3 Facilities (PRTF) Act is amended by changing Sections 10 and
4 15 as follows:
5 (405 ILCS 142/10)
6 Sec. 10. PRTF services.
7 (a) The Department shall establish an Illinois Psychiatric
8 Residential Treatment Facilities (PRTF) program that is
9 family-driven, youth-guided, and trauma-informed, and includes
10 youth and family involvement in all aspects of care planning.
11 The Illinois PRTF program design shall establish meaningful
12 opportunities for youth and families to be involved in the
13 design, monitoring, and oversight of PRTF services.
14 (b) By September 1, 2027 By January 1, 2026, the
15 Department shall submit a State Plan Amendment to the Centers
16 for Medicare and Medicaid Services to establish coverage of
17 federally authorized, medically necessary inpatient
18 psychiatric services delivered by a certified PRTF to medical
19 assistance beneficiaries under 21 years of age.
20 (c) The Department shall adopt rules to implement the
21 Illinois PRTF program. The rules may establish the services,
22 standards, and requirements for participation in the program
23 to comply with all applicable federal statutes, regulations,
SB3365 Enrolled - 244 - LRB104 18483 SSS 31925 b
1 requirements, and policies. The rules proposed by the
2 Department may take into consideration the recommendations of
3 the PRTF Advisory Committee, as outlined in Section 20. At a
4 minimum, the rules shall include the following:
5 (1) Certification and participation requirements for
6 PRTF providers in compliance with all applicable federal
7 laws, regulations, requirements, and policies, including
8 those found at 42 CFR 441, Subpart D and 42 CFR 483,
9 Subpart G or any successor regulations.
10 (2) Monitoring and oversight of PRTF services,
11 including on-site review protocols that include scheduled
12 and unannounced on-site visits. Each provider seeking PRTF
13 certification shall minimally have an on-site review prior
14 to initiating services and all PRTFs shall have at least
15 one on-site review annually thereafter.
16 (3) Utilization management criteria to ensure that
17 PRTF services are provided as medically necessary and
18 emphasize clinically appropriate patient transitions back
19 to the community, including, but not limited to, service
20 authorization, documentation, and treatment plan
21 requirements for initial stay reviews and continued stay
22 reviews.
23 (4) A limit on allowable beds at any one PRTF, not to
24 exceed 40 total beds, unless waived in writing by the
25 Director of the Department.
26 (5) A limit on the number of new PRTF facilities to be
SB3365 Enrolled - 245 - LRB104 18483 SSS 31925 b
1 certified in any State fiscal year.
2 (6) A requirement that PRTFs are distinct, standalone
3 non-hospital entities not physically attached or adjacent
4 to any other type of facility engaged in providing
5 congregate care.
6 (7) A requirement that, in order to obtain PRTF
7 certification, providers must undergo a survey from the
8 State Survey Agency, the Department of Public Health, to
9 establish the provider's compliance with the Conditions of
10 Participation for PRTFs outlined in 42 CFR 483, Subpart G
11 and the Interpretive Guidelines issued by the Centers for
12 Medicare and Medicaid Services.
13 (8) A requirement that, in order to obtain PRTF
14 certification, providers be accredited from one of the
15 following organizations identified in 42 CFR 441.151, or
16 any successor regulations:
17 (i) Joint Commission on Accreditation of
18 Healthcare Organizations.
19 (ii) The Commission on Accreditation of
20 Rehabilitation Facilities.
21 (iii) The Council on Accreditation of Services for
22 Families and Children.
23 (iv) Any other accrediting organization with
24 comparable standards recognized by the Department.
25 (9) Requirements for the reporting of emergency safety
26 interventions and serious occurrences to the Department
SB3365 Enrolled - 246 - LRB104 18483 SSS 31925 b
1 and the State-designated Protection and Advocacy System no
2 later than the close of business the next business day
3 after the intervention or occurrence.
4 (Source: P.A. 104-147, eff. 8-1-25.)
5 (405 ILCS 142/15)
6 Sec. 15. PRTF capacity analysis.
7 (a) The Department shall establish, and update as needed,
8 a methodology for completing a statewide PRTF capacity
9 analysis for the purposes of identifying capacity needs for
10 PRTF services under the Illinois Medical Assistance Program.
11 The Department shall utilize the PRTF capacity analysis to
12 inform its certification and enrollment of PRTF providers. The
13 capacity analysis shall minimally include:
14 (1) An analysis of aggregate service utilization data
15 for Medicaid eligible individuals under the age of 21,
16 including community-based services, behavioral health
17 crisis services, and inpatient psychiatric hospitalization
18 services.
19 (2) Identification of locations across the State with
20 demonstrated need for PRTF services and locations with
21 demonstrated surplus of PRTF service capacity.
22 (3) Consideration of specialized treatment needs based
23 on increased utilization of out-of-state facilities to
24 address specialized treatment needs.
25 (4) Other factors of consideration identified by the
SB3365 Enrolled - 247 - LRB104 18483 SSS 31925 b
1 Department as necessary to support access to care,
2 compliance with the federal Medicaid program, and all
3 other applicable federal or State laws, regulations,
4 policies, requirements, and programs impacting Illinois'
5 children's behavioral health service delivery system.
6 (5) Recommendations to the Department and the PRTF
7 Advisory Committee on capacity needs within the Illinois
8 PRTF program. The recommendations shall seek to avoid the
9 concentration of PRTF facilities in any particular
10 community or area of the State to promote access for
11 families or guardians to visit patients when appropriate.
12 (b) The Department's methodology, completed analyses, and
13 outcomes shall be published on its website, with an initial
14 PRTF capacity analysis to be published by no later than April
15 1, 2027 January 1, 2026.
16 (c) The Department's PRTF capacity analysis shall be
17 updated at a minimum of every 5 years and shall be performed
18 consistent with the Department's published methodology.
19 (Source: P.A. 104-147, eff. 8-1-25.)
20 ARTICLE 185.
21 Section 185-5. The Illinois Public Aid Code is amended by
22 changing Section 1-8.5 as follows:
23 (305 ILCS 5/1-8.5)
SB3365 Enrolled - 248 - LRB104 18483 SSS 31925 b
1 Sec. 1-8.5. Eligibility for medical assistance during
2 periods of incarceration or detention.
3 (a) To the extent permitted by federal law and
4 notwithstanding any other provision of this Code, the
5 Department of Healthcare and Family Services shall not cancel
6 a person's eligibility for medical assistance, nor shall the
7 Department deny a person's application for medical assistance,
8 solely because that person has become or is an inmate of a
9 public institution, including, but not limited to, a county
10 jail, juvenile detention center, or State correctional
11 facility. The person may be and remain enrolled for medical
12 assistance as long as all other eligibility criteria are met.
13 (b) The Department may adopt rules to permit a person to
14 apply for medical assistance while he or she is an inmate of a
15 public institution as described in subsection (a). The rules
16 may limit applications to persons who would be likely to
17 qualify for medical assistance if they resided in the
18 community. Any such person who is not already enrolled for
19 medical assistance may apply for medical assistance prior to
20 the date of scheduled release or discharge from a penal
21 institution or county jail or similar status.
22 (c) Except as provided under Section 17 of the County Jail
23 Act, the Department shall not be responsible to provide
24 medical assistance under this Code for any medical care,
25 services, or supplies provided to a person while he or she is
26 an inmate of a public institution as described in subsection
SB3365 Enrolled - 249 - LRB104 18483 SSS 31925 b
1 (a). The responsibility for providing medical care shall
2 remain as otherwise provided by law with the Department of
3 Corrections, county, or other arresting authority. The
4 Department may seek federal financial participation, to the
5 extent that it is available and with the cooperation of the
6 Department of Juvenile Justice, the Department of Corrections,
7 or the relevant county, for the costs of those services.
8 (c-1) Notwithstanding subsection (c), the Department may
9 provide medical assistance under this Code for medical care,
10 services, and supplies provided to a person while he or she is
11 an inmate of a public institution as described in subsection
12 (a) only to the extent required by the federal Medicaid
13 program, the Children's Health Insurance Program, or otherwise
14 authorized under a federally approved 1115 Waiver, State Plan
15 Amendment, or other federal authority. The medical care,
16 services, and supplies covered, and any other standards,
17 limitations, or conditions for eligibility and coverage, shall
18 be established by rule by the Department in accordance with
19 the applicable federal requirement, waiver, State Plan
20 amendment, or other authority.
21 (d) To the extent permitted under State and federal law,
22 the Department shall develop procedures to expedite required
23 periodic reviews of continued eligibility for persons
24 described in subsection (a).
25 (e) Counties, the Department of Juvenile Justice, the
26 Department of Human Services, and the Department of
SB3365 Enrolled - 250 - LRB104 18483 SSS 31925 b
1 Corrections shall cooperate with the Department in
2 administering this Section. That cooperation shall include
3 managing eligibility processing and sharing information
4 sufficient to inform the Department, in a manner established
5 by the Department, that a person enrolled in the medical
6 assistance program has been detained or incarcerated.
7 (f) The Department shall resume responsibility for
8 providing medical assistance upon release of the person to the
9 community as long as all of the following apply:
10 (1) The person is enrolled for medical assistance at
11 the time of release.
12 (2) Neither a county, the Department of Juvenile
13 Justice, the Department of Corrections, nor any other
14 criminal justice authority continues to bear
15 responsibility for the person's medical care.
16 (3) The county, the Department of Juvenile Justice, or
17 the Department of Corrections provides timely notice of
18 the date of release in a manner established by the
19 Department.
20 (g) This Section applies on and after December 31, 2011.
21 (Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)
22 ARTICLE 190.
23 Section 190-5. The Illinois Public Aid Code is amended by
24 changing Sections 5-30.1 and 5-30.18 as follows:
SB3365 Enrolled - 251 - LRB104 18483 SSS 31925 b
1 (305 ILCS 5/5-30.1)
2 Sec. 5-30.1. Managed care protections.
3 (a) As used in this Section:
4 "Managed care organization" or "MCO" means any entity
5 which contracts with the Department to provide services where
6 payment for medical services is made on a capitated basis.
7 "Emergency services" means health care items and services,
8 including inpatient and outpatient hospital services,
9 furnished or required to evaluate and stabilize an emergency
10 medical condition. "Emergency services" include inpatient
11 stabilization services furnished during the inpatient
12 stabilization period. "Emergency services" do not include
13 post-stabilization medical services.
14 "Emergency medical condition" means a medical condition
15 manifesting itself by acute symptoms of sufficient severity,
16 regardless of the final diagnosis given, such that a prudent
17 layperson, who possesses an average knowledge of health and
18 medicine, could reasonably expect the absence of immediate
19 medical attention to result in:
20 (1) placing the health of the individual (or, with
21 respect to a pregnant woman, the health of the woman or her
22 unborn child) in serious jeopardy;
23 (2) serious impairment to bodily functions;
24 (3) serious dysfunction of any bodily organ or part;
25 (4) inadequately controlled pain; or
SB3365 Enrolled - 252 - LRB104 18483 SSS 31925 b
1 (5) with respect to a pregnant woman who is having
2 contractions:
3 (A) inadequate time to complete a safe transfer to
4 another hospital before delivery; or
5 (B) a transfer to another hospital may pose a
6 threat to the health or safety of the woman or unborn
7 child.
8 "Emergency medical screening examination" means a medical
9 screening examination and evaluation by a physician licensed
10 to practice medicine in all its branches or, to the extent
11 permitted by applicable laws, by other appropriately licensed
12 personnel under the supervision of or in collaboration with a
13 physician licensed to practice medicine in all its branches to
14 determine whether the need for emergency services exists.
15 "Health care services" means mean any medical or
16 behavioral health services covered under the medical
17 assistance program that are subject to review under a service
18 authorization program.
19 "Inpatient stabilization period" means the initial 72
20 hours of inpatient stabilization services, beginning from the
21 date and time of the order for inpatient admission to the
22 hospital.
23 "Inpatient stabilization services" means mean emergency
24 services furnished in the inpatient setting at a hospital
25 pursuant to an order for inpatient admission by a physician or
26 other qualified practitioner who has admitting privileges at
SB3365 Enrolled - 253 - LRB104 18483 SSS 31925 b
1 the hospital, as permitted by State law, to stabilize an
2 emergency medical condition following an emergency medical
3 screening examination.
4 "Post-stabilization medical services" means health care
5 services provided to an enrollee that are furnished in a
6 hospital by a provider that is qualified to furnish such
7 services and determined to be medically necessary by the
8 provider and directly related to the emergency medical
9 condition following stabilization.
10 "Provider" means a facility or individual who is actively
11 enrolled in the medical assistance program and licensed or
12 otherwise authorized to order, prescribe, refer, or render
13 health care services in this State.
14 "Service authorization determination" means a decision
15 made by a service authorization program in advance of,
16 concurrent to, or after the provision of a health care service
17 to approve, change the level of care, partially deny, deny, or
18 otherwise limit coverage and reimbursement for a health care
19 service upon review of a service authorization request.
20 "Service authorization program" means any utilization
21 review, utilization management, peer review, quality review,
22 or other medical management activity conducted by an MCO, or
23 its contracted utilization review organization, including, but
24 not limited to, prior authorization, prior approval,
25 pre-certification, concurrent review, retrospective review, or
26 certification of admission, of health care services provided
SB3365 Enrolled - 254 - LRB104 18483 SSS 31925 b
1 in the inpatient or outpatient hospital setting.
2 "Service authorization request" means a request by a
3 provider to a service authorization program to determine
4 whether a health care service meets the reimbursement
5 eligibility requirements for medically necessary, clinically
6 appropriate care, resulting in the issuance of a service
7 authorization determination.
8 "Utilization review organization" or "URO" means an MCO's
9 utilization review department or a peer review organization or
10 quality improvement organization that contracts with an MCO to
11 administer a service authorization program and make service
12 authorization determinations.
13 (b) As provided by Section 5-16.12, managed care
14 organizations are subject to the provisions of the Managed
15 Care Reform and Patient Rights Act.
16 (c) An MCO shall pay any provider of emergency services,
17 including for inpatient stabilization services provided during
18 the inpatient stabilization period, that does not have in
19 effect a contract with the contracted Medicaid MCO. The
20 default rate of reimbursement shall be the rate paid under
21 Illinois Medicaid fee-for-service program methodology,
22 including all policy adjusters, including but not limited to
23 Medicaid High Volume Adjustments, Medicaid Percentage
24 Adjustments, Outpatient High Volume Adjustments, and all
25 outlier add-on adjustments to the extent such adjustments are
26 incorporated in the development of the applicable MCO
SB3365 Enrolled - 255 - LRB104 18483 SSS 31925 b
1 capitated rates.
2 (d) (Blank).
3 (e) Notwithstanding any other provision of law, the
4 following requirements apply to MCOs in determining payment
5 for all emergency services, including inpatient stabilization
6 services provided during the inpatient stabilization period:
7 (1) The MCO shall not impose any service authorization
8 program requirements for emergency services, including,
9 but not limited to, prior authorization, prior approval,
10 pre-certification, certification of admission, concurrent
11 review, or retrospective review.
12 (A) Notification period: Hospitals shall notify
13 the enrollee's Medicaid MCO within 48 hours of the
14 date and time the order for inpatient admission is
15 written. Notification shall be limited to advising the
16 MCO that the patient has been admitted to a hospital
17 inpatient level of care.
18 (B) If the admitting hospital complies with the
19 notification provisions of subparagraph (A), the
20 Medicaid MCO may not initiate concurrent review before
21 the end of the inpatient stabilization period. If the
22 admitting hospital does not comply with the
23 notification requirements in subparagraph (A), the
24 Medicaid MCO may initiate concurrent review for the
25 continuation of the stay beginning at the end of the
26 48-hour notification period.
SB3365 Enrolled - 256 - LRB104 18483 SSS 31925 b
1 (C) Coverage for services provided during the
2 48-hour notification period may not be retrospectively
3 denied.
4 (2) The MCO shall cover emergency services provided to
5 enrollees who are temporarily away from their residence
6 and outside the contracting area to the extent that the
7 enrollees would be entitled to the emergency services if
8 they still were within the contracting area.
9 (3) The MCO shall have no obligation to cover
10 emergency services provided on an emergency basis that are
11 not covered services under the contract between the MCO
12 and the Department.
13 (4) The MCO shall not condition coverage for emergency
14 services on the treating provider notifying the MCO of the
15 enrollee's emergency medical screening examination and
16 treatment within 10 days after presentation for emergency
17 services.
18 (5) The determination of the attending emergency
19 physician, or the practitioner responsible for the
20 enrollee's care at the hospital, of whether an enrollee
21 requires inpatient stabilization services, can be
22 stabilized in the outpatient setting, or is sufficiently
23 stabilized for discharge or transfer to another setting,
24 shall be binding on the MCO. The MCO shall cover and
25 reimburse providers for emergency services as billed by
26 the provider for all enrollees whether the emergency
SB3365 Enrolled - 257 - LRB104 18483 SSS 31925 b
1 services are provided by an affiliated or non-affiliated
2 provider, except in cases of fraud. The MCO shall
3 reimburse inpatient stabilization services provided during
4 the inpatient stabilization period and billed as inpatient
5 level of care based on the appropriate inpatient
6 reimbursement methodology.
7 (6) The MCO's financial responsibility for
8 post-stabilization medical services it has not
9 pre-approved ends when:
10 (A) a plan physician with privileges at the
11 treating hospital assumes responsibility for the
12 enrollee's care;
13 (B) a plan physician assumes responsibility for
14 the enrollee's care through transfer;
15 (C) a contracting entity representative and the
16 treating physician reach an agreement concerning the
17 enrollee's care; or
18 (D) the enrollee is discharged.
19 (e-5) An MCO shall pay for all post-stabilization medical
20 services as a covered service in any of the following
21 situations:
22 (1) the MCO or its URO authorized such services;
23 (2) such services were administered to maintain the
24 enrollee's stabilized condition within one hour after a
25 request to the MCO for authorization of further
26 post-stabilization services;
SB3365 Enrolled - 258 - LRB104 18483 SSS 31925 b
1 (3) the MCO or its URO did not respond to a request to
2 authorize such services within one hour;
3 (4) the MCO or its URO could not be contacted; or
4 (5) the MCO or its URO and the treating provider, if
5 the treating provider is a non-affiliated provider, could
6 not reach an agreement concerning the enrollee's care and
7 an affiliated provider was unavailable for a consultation,
8 in which case the MCO must pay for such services rendered
9 by the treating non-affiliated provider until an
10 affiliated provider was reached and either concurred with
11 the treating non-affiliated provider's plan of care or
12 assumed responsibility for the enrollee's care. Such
13 payment shall be made at the default rate of reimbursement
14 paid under the State's Medicaid fee-for-service program
15 methodology, including all policy adjusters, including,
16 but not limited to, Medicaid High Volume Adjustments,
17 Medicaid Percentage Adjustments, Outpatient High Volume
18 Adjustments, and all outlier add-on adjustments to the
19 extent that such adjustments are incorporated in the
20 development of the applicable MCO capitated rates.
21 (f) Network adequacy and transparency.
22 (1) The Department shall:
23 (A) ensure that an adequate provider network is in
24 place, taking into consideration health professional
25 shortage areas and medically underserved areas;
26 (B) publicly release an explanation of its process
SB3365 Enrolled - 259 - LRB104 18483 SSS 31925 b
1 for analyzing network adequacy;
2 (C) periodically ensure that an MCO continues to
3 have an adequate network in place;
4 (D) require MCOs, including Medicaid Managed Care
5 Entities as defined in Section 5-30.2, to meet
6 provider directory requirements under Section 5-30.3;
7 (E) require MCOs to ensure that any
8 Medicaid-certified provider under contract with an MCO
9 and previously submitted on a roster on the date of
10 service is paid for any medically necessary,
11 Medicaid-covered, and authorized service rendered to
12 any of the MCO's enrollees, regardless of inclusion on
13 the MCO's published and publicly available directory
14 of available providers; and
15 (F) require MCOs, including Medicaid Managed Care
16 Entities as defined in Section 5-30.2, to meet each of
17 the requirements under subsection (d-5) of Section 10
18 of the Network Adequacy and Transparency Act; with
19 necessary exceptions to the MCO's network to ensure
20 that admission and treatment with a provider or at a
21 treatment facility in accordance with the network
22 adequacy standards in paragraph (3) of subsection
23 (d-5) of Section 10 of the Network Adequacy and
24 Transparency Act is limited to providers or facilities
25 that are Medicaid certified.
26 (2) Each MCO shall confirm its receipt of information
SB3365 Enrolled - 260 - LRB104 18483 SSS 31925 b
1 submitted specific to physician or dentist additions or
2 physician or dentist deletions from the MCO's provider
3 network within 3 days after receiving all required
4 information from contracted physicians or dentists, and
5 electronic physician and dental directories must be
6 updated consistent with current rules as published by the
7 Centers for Medicare and Medicaid Services or its
8 successor agency.
9 (g) Timely payment of claims.
10 (1) The MCO shall pay a claim within 30 days of
11 receiving a claim that contains all the essential
12 information needed to adjudicate the claim.
13 (2) The MCO shall notify the billing party of its
14 inability to adjudicate a claim within 30 days of
15 receiving that claim.
16 (3) The MCO shall pay a penalty that is at least equal
17 to the timely payment interest penalty imposed under
18 Section 368a of the Illinois Insurance Code for any claims
19 not timely paid.
20 (A) When an MCO is required to pay a timely payment
21 interest penalty to a provider, the MCO must calculate
22 and pay the timely payment interest penalty that is
23 due to the provider within 30 days after the payment of
24 the claim. In no event shall a provider be required to
25 request or apply for payment of any owed timely
26 payment interest penalties.
SB3365 Enrolled - 261 - LRB104 18483 SSS 31925 b
1 (B) Such payments shall be reported separately
2 from the claim payment for services rendered to the
3 MCO's enrollee and clearly identified as interest
4 payments.
5 (4)(A) The Department shall require MCOs to expedite
6 payments to providers identified on the Department's
7 expedited provider list, determined in accordance with 89
8 Ill. Adm. Code 140.71(b), on a schedule at least as
9 frequently as the providers are paid under the
10 Department's fee-for-service expedited provider schedule.
11 (B) Compliance with the expedited provider requirement
12 may be satisfied by an MCO through the use of a Periodic
13 Interim Payment (PIP) program that has been mutually
14 agreed to and documented between the MCO and the provider,
15 if the PIP program ensures that any expedited provider
16 receives regular and periodic payments based on prior
17 period payment experience from that MCO. Total payments
18 under the PIP program may be reconciled against future PIP
19 payments on a schedule mutually agreed to between the MCO
20 and the provider.
21 (C) The Department shall share at least monthly its
22 expedited provider list and the frequency with which it
23 pays providers on the expedited list.
24 (g-5) Recognizing that the rapid transformation of the
25 Illinois Medicaid program may have unintended operational
26 challenges for both payers and providers:
SB3365 Enrolled - 262 - LRB104 18483 SSS 31925 b
1 (1) in no instance shall a medically necessary covered
2 service rendered in good faith, based upon eligibility
3 information documented by the provider, be denied coverage
4 or diminished in payment amount if the eligibility or
5 coverage information available at the time the service was
6 rendered is later found to be inaccurate in the assignment
7 of coverage responsibility between MCOs or the
8 fee-for-service system, except for instances when an
9 individual is deemed to have not been eligible for
10 coverage under the Illinois Medicaid program; and
11 (2) the Department shall, by December 31, 2016, adopt
12 rules establishing policies that shall be included in the
13 Medicaid managed care policy and procedures manual
14 addressing payment resolutions in situations in which a
15 provider renders services based upon information obtained
16 after verifying a patient's eligibility and coverage plan
17 through either the Department's current enrollment system
18 or a system operated by the coverage plan identified by
19 the patient presenting for services:
20 (A) such medically necessary covered services
21 shall be considered rendered in good faith;
22 (B) such policies and procedures shall be
23 developed in consultation with industry
24 representatives of the Medicaid managed care health
25 plans and representatives of provider associations
26 representing the majority of providers within the
SB3365 Enrolled - 263 - LRB104 18483 SSS 31925 b
1 identified provider industry; and
2 (C) such rules shall be published for a review and
3 comment period of no less than 30 days on the
4 Department's website with final rules remaining
5 available on the Department's website.
6 The rules on payment resolutions shall include, but
7 not be limited to:
8 (A) the extension of the timely filing period;
9 (B) retroactive prior authorizations; and
10 (C) guaranteed minimum payment rate of no less
11 than the current, as of the date of service,
12 fee-for-service rate, plus all applicable add-ons,
13 when the resulting service relationship is out of
14 network.
15 The rules shall be applicable for both MCO coverage
16 and fee-for-service coverage.
17 If the fee-for-service system is ultimately determined to
18 have been responsible for coverage on the date of service, the
19 Department shall provide for an extended period for claims
20 submission outside the standard timely filing requirements.
21 (g-6) MCO Performance Metrics Report.
22 (1) The Department shall publish, on at least a
23 quarterly basis, each MCO's operational performance,
24 including, but not limited to, the following categories of
25 metrics:
26 (A) claims payment, including timeliness and
SB3365 Enrolled - 264 - LRB104 18483 SSS 31925 b
1 accuracy;
2 (B) prior authorizations;
3 (C) grievance and appeals;
4 (D) utilization statistics;
5 (E) provider disputes;
6 (F) provider credentialing; and
7 (G) member and provider customer service.
8 (2) The Department shall ensure that the metrics
9 report is accessible to providers online by January 1,
10 2017.
11 (3) The metrics shall be developed in consultation
12 with industry representatives of the Medicaid managed care
13 health plans and representatives of associations
14 representing the majority of providers within the
15 identified industry.
16 (4) Metrics shall be defined and incorporated into the
17 applicable Managed Care Policy Manual issued by the
18 Department.
19 (g-7) MCO claims processing and performance analysis. In
20 order to monitor MCO payments to hospital providers, pursuant
21 to Public Act 100-580, the Department shall post an analysis
22 of MCO claims processing and payment performance on its
23 website every 6 months. Such analysis shall include a review
24 and evaluation of a representative sample of hospital claims
25 that are rejected and denied for clean and unclean claims and
26 the top 5 reasons for such actions and timeliness of claims
SB3365 Enrolled - 265 - LRB104 18483 SSS 31925 b
1 adjudication, which identifies the percentage of claims
2 adjudicated within 30, 60, 90, and over 90 days, and the dollar
3 amounts associated with those claims.
4 (g-8) Dispute resolution process. The Department shall
5 maintain a provider complaint portal through which a provider
6 can submit to the Department unresolved disputes with an MCO.
7 An unresolved dispute means an MCO's decision that denies in
8 whole or in part a claim for reimbursement to a provider for
9 health care services rendered by the provider to an enrollee
10 of the MCO with which the provider disagrees. Disputes shall
11 not be submitted to the portal until the provider has availed
12 itself of the MCO's internal dispute resolution process.
13 Disputes that are submitted to the MCO internal dispute
14 resolution process may be submitted to the Department of
15 Healthcare and Family Services' complaint portal no sooner
16 than 30 days after submitting to the MCO's internal process
17 and not later than 30 days after the unsatisfactory resolution
18 of the internal MCO process or 60 days after submitting the
19 dispute to the MCO internal process. Multiple claim disputes
20 involving the same MCO may be submitted in one complaint,
21 regardless of whether the claims are for different enrollees,
22 when the specific reason for non-payment of the claims
23 involves a common question of fact or policy. Within 10
24 business days of receipt of a complaint, the Department shall
25 present such disputes to the appropriate MCO, which shall then
26 have 30 days to issue its written proposal to resolve the
SB3365 Enrolled - 266 - LRB104 18483 SSS 31925 b
1 dispute. The Department may grant one 30-day extension of this
2 time frame to one of the parties to resolve the dispute. If the
3 dispute remains unresolved at the end of this time frame or the
4 provider is not satisfied with the MCO's written proposal to
5 resolve the dispute, the provider may, within 30 days, request
6 the Department to review the dispute and make a final
7 determination. Within 30 days of the request for Department
8 review of the dispute, both the provider and the MCO shall
9 present all relevant information to the Department for
10 resolution and make individuals with knowledge of the issues
11 available to the Department for further inquiry if needed.
12 Within 30 days of receiving the relevant information on the
13 dispute, or the lapse of the period for submitting such
14 information, the Department shall issue a written decision on
15 the dispute based on contractual terms between the provider
16 and the MCO, contractual terms between the MCO and the
17 Department of Healthcare and Family Services and applicable
18 Medicaid policy. The decision of the Department shall be
19 final. By January 1, 2020, the Department shall establish by
20 rule further details of this dispute resolution process.
21 Disputes between MCOs and providers presented to the
22 Department for resolution are not contested cases, as defined
23 in Section 1-30 of the Illinois Administrative Procedure Act,
24 conferring any right to an administrative hearing.
25 (g-9)(1) The Department shall publish annually on its
26 website a report on the calculation of each managed care
SB3365 Enrolled - 267 - LRB104 18483 SSS 31925 b
1 organization's medical loss ratio showing the following:
2 (A) Premium revenue, with appropriate adjustments.
3 (B) Benefit expense, setting forth the aggregate
4 amount spent for the following:
5 (i) Direct paid claims.
6 (ii) Subcapitation payments.
7 (iii) Other claim payments.
8 (iv) Direct reserves.
9 (v) Gross recoveries.
10 (vi) Expenses for activities that improve health
11 care quality as allowed by the Department.
12 (2) The medical loss ratio shall be calculated consistent
13 with federal law and regulation following a claims runout
14 period determined by the Department.
15 (g-10)(1) "Liability effective date" means the date on
16 which an MCO becomes responsible for payment for medically
17 necessary and covered services rendered by a provider to one
18 of its enrollees in accordance with the contract terms between
19 the MCO and the provider. The liability effective date shall
20 be the later of:
21 (A) The execution date of a network participation
22 contract agreement.
23 (B) The date the provider or its representative
24 submits to the MCO the complete and accurate standardized
25 roster form for the provider in the format approved by the
26 Department.
SB3365 Enrolled - 268 - LRB104 18483 SSS 31925 b
1 (C) The provider effective date contained within the
2 Department's provider enrollment subsystem within the
3 Illinois Medicaid Program Advanced Cloud Technology
4 (IMPACT) System.
5 (2) The standardized roster form may be submitted to the
6 MCO at the same time that the provider submits an enrollment
7 application to the Department through IMPACT.
8 (3) By October 1, 2019, the Department shall require all
9 MCOs to update their provider directory with information for
10 new practitioners of existing contracted providers within 30
11 days of receipt of a complete and accurate standardized roster
12 template in the format approved by the Department provided
13 that the provider is effective in the Department's provider
14 enrollment subsystem within the IMPACT system. Such provider
15 directory shall be readily accessible for purposes of
16 selecting an approved health care provider and comply with all
17 other federal and State requirements.
18 (g-11) The Department shall work with relevant
19 stakeholders on the development of operational guidelines to
20 enhance and improve operational performance of Illinois'
21 Medicaid managed care program, including, but not limited to,
22 improving provider billing practices, reducing claim
23 rejections and inappropriate payment denials, and
24 standardizing processes, procedures, definitions, and response
25 timelines, with the goal of reducing provider and MCO
26 administrative burdens and conflict. The Department shall
SB3365 Enrolled - 269 - LRB104 18483 SSS 31925 b
1 include a report on the progress of these program improvements
2 and other topics in its Fiscal Year 2020 annual report to the
3 General Assembly.
4 (g-12) Notwithstanding any other provision of law, if the
5 Department or an MCO requires submission of a claim for
6 payment in a non-electronic format, a provider shall always be
7 afforded a period of no less than 90 business days, as a
8 correction period, following any notification of rejection by
9 either the Department or the MCO to correct errors or
10 omissions in the original submission.
11 Under no circumstances, either by an MCO or under the
12 State's fee-for-service system, shall a provider be denied
13 payment for failure to comply with any timely submission
14 requirements under this Code or under any existing contract,
15 unless the non-electronic format claim submission occurs after
16 the initial 180 days following the latest date of service on
17 the claim, or after the 90 business days correction period
18 following notification to the provider of rejection or denial
19 of payment.
20 (g-13) Utilization Review Standardization and
21 Transparency.
22 (1) To ensure greater standardization and transparency
23 related to service authorization determinations, for all
24 individuals covered under the medical assistance program,
25 including both the fee-for-service and managed care
26 programs, the Department shall, in consultation with the
SB3365 Enrolled - 270 - LRB104 18483 SSS 31925 b
1 MCOs, a statewide association representing the MCOs, a
2 statewide association representing the majority of
3 Illinois hospitals, a statewide association representing
4 physicians, or any other interested parties deemed
5 appropriate by the Department, adopt administrative rules
6 consistent with this subsection, in accordance with the
7 Illinois Administrative Procedure Act.
8 (2) No later than July 1, 2025, the Department shall
9 in accordance with the Illinois Administrative Procedure
10 Act file emergency rules, and adopt permanent rules no
11 later than October 1, 2025, which govern MCO practices for
12 dates of services on and after July 1, 2025, as follows:
13 (A) guidelines related to the publication of MCO
14 authorization policies;
15 (B) procedures that, due to medical complexity,
16 must be reimbursed under the applicable inpatient
17 methodology, when provided in the inpatient setting
18 and billed as an inpatient service;
19 (C) standardization of administrative forms used
20 in the member appeal process;
21 (D) limitations on second or subsequent medical
22 necessity review of a health care service already
23 authorized by the MCO or URO under a service
24 authorization program;
25 (E) standardization of peer-to-peer processes and
26 timelines;
SB3365 Enrolled - 271 - LRB104 18483 SSS 31925 b
1 (F) defined criteria for urgent and standard
2 post-acute care and long-term acute care service
3 authorization requests; and
4 (G) standardized criteria for service
5 authorization programs for authorization of admission
6 to a long-term acute care hospital.
7 (3) The Department shall expand the scope of the
8 quality and compliance audits conducted by its contracted
9 external quality review organization to include, but not
10 be limited to:
11 (A) an analysis of the Medicaid MCO's compliance
12 with nationally recognized clinical decision
13 guidelines;
14 (B) an analysis that compares and contrasts the
15 Medicaid MCO's service authorization determination
16 outcomes to the outcomes of each other MCO plan and the
17 State's fee-for-service program model to evaluate
18 whether service authorization determinations are being
19 made consistently by all Medicaid MCOs to ensure that
20 all individuals are being treated in accordance with
21 equitable standards of care;
22 (C) an analysis, for each Medicaid MCO, of the
23 number of service authorization requests, including
24 requests for concurrent review and certification of
25 admissions, received, initially denied, overturned
26 through any post-denial process including, but not
SB3365 Enrolled - 272 - LRB104 18483 SSS 31925 b
1 limited to, enrollee or provider appeal, peer-to-peer
2 review, or the provider dispute resolution process,
3 denied but approved for a lower or different level of
4 care, and the number denied on final determination;
5 and
6 (D) provide a written report to the General
7 Assembly, detailing the items listed in this
8 subsection and any other metrics deemed necessary by
9 the Department, by the second April, following June 7,
10 2024 (the effective date of Public Act 103-593), and
11 each April thereafter. The Department shall make this
12 report available within 30 days of delivery to the
13 General Assembly, on its public facing website.
14 (h) The Department shall not expand mandatory MCO
15 enrollment into new counties beyond those counties already
16 designated by the Department as of June 1, 2014 for the
17 individuals whose eligibility for medical assistance is not
18 the seniors or people with disabilities population until the
19 Department provides an opportunity for accountable care
20 entities and MCOs to participate in such newly designated
21 counties.
22 (h-5) Leading indicator data sharing. By January 1, 2024,
23 the Department shall obtain input from the Department of Human
24 Services, the Department of Juvenile Justice, the Department
25 of Children and Family Services, the State Board of Education,
26 managed care organizations, providers, and clinical experts to
SB3365 Enrolled - 273 - LRB104 18483 SSS 31925 b
1 identify and analyze key indicators and data elements that can
2 be used in an analysis of lead indicators from assessments and
3 data sets available to the Department that can be shared with
4 managed care organizations and similar care coordination
5 entities contracted with the Department as leading indicators
6 for elevated behavioral health crisis risk for children,
7 including data sets such as the Illinois Medicaid
8 Comprehensive Assessment of Needs and Strengths (IM-CANS),
9 calls made to the State's Crisis and Referral Entry Services
10 (CARES) hotline, health services information from Health and
11 Human Services Innovators, or other data sets that may include
12 key indicators. The workgroup shall complete its
13 recommendations for leading indicator data elements on or
14 before September 1, 2024. To the extent permitted by State and
15 federal law, the identified leading indicators shall be shared
16 with managed care organizations and similar care coordination
17 entities contracted with the Department on or before December
18 1, 2024 for the purpose of improving care coordination with
19 the early detection of elevated risk. Leading indicators shall
20 be reassessed annually with stakeholder input. The Department
21 shall implement guidance to managed care organizations and
22 similar care coordination entities contracted with the
23 Department, so that the managed care organizations and care
24 coordination entities respond to lead indicators with services
25 and interventions that are designed to help stabilize the
26 child.
SB3365 Enrolled - 274 - LRB104 18483 SSS 31925 b
1 (i) The requirements of this Section apply to contracts
2 with accountable care entities and MCOs entered into, amended,
3 or renewed after June 16, 2014 (the effective date of Public
4 Act 98-651).
5 (j) Health care information released to managed care
6 organizations. A health care provider shall release to a
7 Medicaid managed care organization, upon request, and subject
8 to the Health Insurance Portability and Accountability Act of
9 1996 and any other law applicable to the release of health
10 information, the health care information of the MCO's
11 enrollee, if the enrollee has completed and signed a general
12 release form that grants to the health care provider
13 permission to release the recipient's health care information
14 to the recipient's insurance carrier.
15 (k) The Department of Healthcare and Family Services,
16 managed care organizations, a statewide organization
17 representing hospitals, and a statewide organization
18 representing safety-net hospitals shall explore ways to
19 support billing departments in safety-net hospitals.
20 (l) The requirements of this Section added by Public Act
21 102-4 shall apply to services provided on or after the first
22 day of the month that begins 60 days after April 27, 2021 (the
23 effective date of Public Act 102-4).
24 (m) Except where otherwise expressly specified, the
25 requirements of this Section added by Public Act 103-593 shall
26 apply to services provided on and after July 1, 2027 July 1,
SB3365 Enrolled - 275 - LRB104 18483 SSS 31925 b
1 2026.
2 (Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
3 103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
4 8-15-25.)
5 (305 ILCS 5/5-30.18)
6 (Section scheduled to be repealed on December 31, 2030)
7 Sec. 5-30.18. Service authorization program performance.
8 (a) Definitions. As used in this Section:
9 "Gold Card provider" means a provider identified by each
10 Medicaid Managed Care Organization (MCO) as qualified under
11 the guidelines outlined by the Department in accordance with
12 subsection (c) and thereby granted a service authorization
13 exemption when ordering a health care service.
14 "Health care service" means any medical or behavioral
15 health service covered under the medical assistance program
16 that is rendered in the inpatient or outpatient hospital
17 setting, including hospital-based clinics, and subject to
18 review under a service authorization program.
19 "Provider" means an individual actively enrolled in the
20 medical assistance program and licensed or otherwise
21 authorized to order, prescribe, refer, or render health care
22 services in this State, and, as determined by the Department,
23 may also include hospitals that submit service authorization
24 requests.
25 "Service authorization exemption" means an exception
SB3365 Enrolled - 276 - LRB104 18483 SSS 31925 b
1 granted by a Medicaid MCO to a provider under which all service
2 authorization requests for covered health care services,
3 excluding pharmacy services and durable medical equipment, are
4 automatically deemed to be medically necessary, clinically
5 appropriate, and approved for reimbursement as ordered.
6 "Service authorization program" means any utilization
7 review, utilization management, peer review, quality review,
8 or other medical management activity conducted in advance of,
9 concurrent to, or after the provision of a health care service
10 by a Medicaid MCO, either directly or through a contracted
11 utilization review organization (URO), including, but not
12 limited to, prior authorization, pre-certification,
13 certification of admission, concurrent review, and
14 retrospective review of health care services.
15 "Service authorization request" means a request by a
16 provider to a service authorization program to determine
17 whether a health care service that is otherwise covered under
18 the medical assistance program meets the reimbursement
19 requirements established by the Medicaid MCO, or its
20 contracted URO, for medically necessary, clinically
21 appropriate care and to issue a service authorization
22 determination.
23 "Utilization review organization" or "URO" means a managed
24 care organization or other entity that has established or
25 administers one or more service authorization programs.
26 (b) In consultation with the Medicaid MCOs, a statewide
SB3365 Enrolled - 277 - LRB104 18483 SSS 31925 b
1 association representing managed care organizations, a
2 statewide association representing the majority of Illinois
3 hospitals, and a statewide association representing
4 physicians, the Department shall in accordance with the
5 Illinois Administrative Procedure Act, adopt administrative
6 rules no later than October July 1, 2026, consistent with this
7 Section, to require each Medicaid MCO to identify Gold Card
8 providers with such identification initially being effective
9 for health care services provided on and after January 1, 2027
10 July 1, 2026.
11 (c) The Department shall adopt rules, in accordance with
12 the Illinois Administrative Procedure Act, to implement this
13 Section that include, but are not limited to, the following
14 provisions:
15 (1) Require each Medicaid MCO to provide a service
16 authorization exemption to a provider if the provider has
17 submitted at least 50 service authorization requests to
18 its service authorization program in the preceding
19 calendar year and the service authorization program
20 approved at least 90% of all service authorization
21 requests, regardless of the type of health care services
22 requested.
23 (2) Require that service authorization exemptions be
24 limited to services provided in an inpatient or outpatient
25 hospital setting inclusive of hospital-based clinics.
26 Service authorization exemptions under this Section shall
SB3365 Enrolled - 278 - LRB104 18483 SSS 31925 b
1 not pertain to pharmacy services and durable medical
2 equipment and supplies.
3 (3) The service authorization exemption shall be valid
4 for at least one year, shall be made by each Medicaid MCO
5 or its URO, and shall be binding on the Medicaid MCO and
6 its URO.
7 (4) The provider shall be required to continue to
8 document medically necessary, clinically appropriate care
9 and submit such documentation to the Medicaid MCO for the
10 purpose of continuous performance monitoring. If a
11 provider fails to maintain the 90% service authorization
12 standard, as determined on no more frequent a basis than
13 bi-annually, the provider's service authorization
14 exemption is subject to temporary or permanent suspension.
15 (5) Require that each Medicaid MCO publish on its
16 provider portal a list of all providers that have
17 qualified for a service authorization exemption or
18 indicate that a provider has qualified for a service
19 authorization exemption on its provider-facing provider
20 roster.
21 (6) Require that no later than June 1 of each calendar
22 year, each Medicaid MCO shall provide written notification
23 to all providers who qualify for a service authorization
24 exemption, for the subsequent State fiscal year.
25 (7) Require that each Medicaid MCO or its URO use the
26 policies and guidelines published by the Department to
SB3365 Enrolled - 279 - LRB104 18483 SSS 31925 b
1 evaluate whether a provider meets the criteria to qualify
2 for a service authorization exemption and the conditions
3 under which a service authorization exemption may be
4 rescinded, including review of the provider's service
5 authorization determinations during the preceding calendar
6 year.
7 (8) Require each Medicaid MCO to provide the
8 Department a list of all providers who were denied a
9 service authorization exemption or had a previously
10 granted service authorization exemption suspended, with
11 such denials being subject to an annual audit conducted by
12 an independent third-party URO to ensure their
13 appropriateness.
14 (A) The independent third-party URO shall issue a
15 written report consistent with this paragraph.
16 (B) The independent third-party URO shall not be
17 owned by, affiliated with, or employed by any Medicaid
18 MCO or its contracted URO, nor shall it have any
19 financial interest in the Medicaid MCO's service
20 authorization exemption program.
21 (d) Each Medicaid MCO must have a standard method to
22 accept and process professional claims and facility claims, as
23 billed by the provider, for a health care service that is
24 rendered, prescribed, or ordered by a provider granted a
25 service authorization exemption, except in cases of fraud.
26 (e) A service authorization program shall not deny,
SB3365 Enrolled - 280 - LRB104 18483 SSS 31925 b
1 partially deny, reduce the level of care, or otherwise limit
2 reimbursement to the rendering or supervising provider,
3 including the rendering facility, for health care services
4 ordered by a provider who qualifies for a service
5 authorization exemption, except in cases of fraud.
6 (f) This Section is repealed on December 31, 2030.
7 (Source: P.A. 103-593, eff. 6-7-24; 104-9, eff. 6-16-25.)
8 ARTICLE 195.
9 Section 195-5. The Illinois Insurance Code is amended by
10 changing Section 370c.1 as follows:
11 (215 ILCS 5/370c.1)
12 Sec. 370c.1. Mental, emotional, nervous, or substance use
13 disorder or condition parity.
14 (a) On and after July 23, 2021 (the effective date of
15 Public Act 102-135), every insurer that amends, delivers,
16 issues, or renews a group or individual policy of accident and
17 health insurance or a qualified health plan offered through
18 the Health Insurance Marketplace in this State providing
19 coverage for hospital or medical treatment and for the
20 treatment of mental, emotional, nervous, or substance use
21 disorders or conditions shall ensure prior to policy issuance
22 that:
23 (1) the financial requirements applicable to such
SB3365 Enrolled - 281 - LRB104 18483 SSS 31925 b
1 mental, emotional, nervous, or substance use disorder or
2 condition benefits are no more restrictive than the
3 predominant financial requirements applied to
4 substantially all hospital and medical benefits covered by
5 the policy and that there are no separate cost-sharing
6 requirements that are applicable only with respect to
7 mental, emotional, nervous, or substance use disorder or
8 condition benefits; and
9 (2) the treatment limitations applicable to such
10 mental, emotional, nervous, or substance use disorder or
11 condition benefits are no more restrictive than the
12 predominant treatment limitations applied to substantially
13 all hospital and medical benefits covered by the policy
14 and that there are no separate treatment limitations that
15 are applicable only with respect to mental, emotional,
16 nervous, or substance use disorder or condition benefits.
17 (b) The following provisions shall apply concerning
18 aggregate lifetime limits:
19 (1) In the case of a group or individual policy of
20 accident and health insurance or a qualified health plan
21 offered through the Health Insurance Marketplace amended,
22 delivered, issued, or renewed in this State on or after
23 September 9, 2015 (the effective date of Public Act
24 99-480) that provides coverage for hospital or medical
25 treatment and for the treatment of mental, emotional,
26 nervous, or substance use disorders or conditions the
SB3365 Enrolled - 282 - LRB104 18483 SSS 31925 b
1 following provisions shall apply:
2 (A) if the policy does not include an aggregate
3 lifetime limit on substantially all hospital and
4 medical benefits, then the policy may not impose any
5 aggregate lifetime limit on mental, emotional,
6 nervous, or substance use disorder or condition
7 benefits; or
8 (B) if the policy includes an aggregate lifetime
9 limit on substantially all hospital and medical
10 benefits (in this subsection referred to as the
11 "applicable lifetime limit"), then the policy shall
12 either:
13 (i) apply the applicable lifetime limit both
14 to the hospital and medical benefits to which it
15 otherwise would apply and to mental, emotional,
16 nervous, or substance use disorder or condition
17 benefits and not distinguish in the application of
18 the limit between the hospital and medical
19 benefits and mental, emotional, nervous, or
20 substance use disorder or condition benefits; or
21 (ii) not include any aggregate lifetime limit
22 on mental, emotional, nervous, or substance use
23 disorder or condition benefits that is less than
24 the applicable lifetime limit.
25 (2) In the case of a policy that is not described in
26 paragraph (1) of subsection (b) of this Section and that
SB3365 Enrolled - 283 - LRB104 18483 SSS 31925 b
1 includes no or different aggregate lifetime limits on
2 different categories of hospital and medical benefits, the
3 Director shall establish rules under which subparagraph
4 (B) of paragraph (1) of subsection (b) of this Section is
5 applied to such policy with respect to mental, emotional,
6 nervous, or substance use disorder or condition benefits
7 by substituting for the applicable lifetime limit an
8 average aggregate lifetime limit that is computed taking
9 into account the weighted average of the aggregate
10 lifetime limits applicable to such categories.
11 (c) The following provisions shall apply concerning annual
12 limits:
13 (1) In the case of a group or individual policy of
14 accident and health insurance or a qualified health plan
15 offered through the Health Insurance Marketplace amended,
16 delivered, issued, or renewed in this State on or after
17 September 9, 2015 (the effective date of Public Act
18 99-480) that provides coverage for hospital or medical
19 treatment and for the treatment of mental, emotional,
20 nervous, or substance use disorders or conditions the
21 following provisions shall apply:
22 (A) if the policy does not include an annual limit
23 on substantially all hospital and medical benefits,
24 then the policy may not impose any annual limits on
25 mental, emotional, nervous, or substance use disorder
26 or condition benefits; or
SB3365 Enrolled - 284 - LRB104 18483 SSS 31925 b
1 (B) if the policy includes an annual limit on
2 substantially all hospital and medical benefits (in
3 this subsection referred to as the "applicable annual
4 limit"), then the policy shall either:
5 (i) apply the applicable annual limit both to
6 the hospital and medical benefits to which it
7 otherwise would apply and to mental, emotional,
8 nervous, or substance use disorder or condition
9 benefits and not distinguish in the application of
10 the limit between the hospital and medical
11 benefits and mental, emotional, nervous, or
12 substance use disorder or condition benefits; or
13 (ii) not include any annual limit on mental,
14 emotional, nervous, or substance use disorder or
15 condition benefits that is less than the
16 applicable annual limit.
17 (2) In the case of a policy that is not described in
18 paragraph (1) of subsection (c) of this Section and that
19 includes no or different annual limits on different
20 categories of hospital and medical benefits, the Director
21 shall establish rules under which subparagraph (B) of
22 paragraph (1) of subsection (c) of this Section is applied
23 to such policy with respect to mental, emotional, nervous,
24 or substance use disorder or condition benefits by
25 substituting for the applicable annual limit an average
26 annual limit that is computed taking into account the
SB3365 Enrolled - 285 - LRB104 18483 SSS 31925 b
1 weighted average of the annual limits applicable to such
2 categories.
3 (d) With respect to mental, emotional, nervous, or
4 substance use disorders or conditions, an insurer shall use
5 policies and procedures for the election and placement of
6 mental, emotional, nervous, or substance use disorder or
7 condition treatment drugs on its their formulary that are no
8 less favorable to the insured as those policies and procedures
9 the insurer uses for the selection and placement of drugs for
10 medical or surgical conditions and shall follow the expedited
11 coverage determination requirements for substance abuse
12 treatment drugs set forth in Section 45.2 of the Managed Care
13 Reform and Patient Rights Act.
14 (e) This Section shall be interpreted in a manner
15 consistent with all applicable federal parity regulations
16 including, but not limited to, the Paul Wellstone and Pete
17 Domenici Mental Health Parity and Addiction Equity Act of
18 2008, final regulations issued under the Paul Wellstone and
19 Pete Domenici Mental Health Parity and Addiction Equity Act of
20 2008 and final regulations applying the Paul Wellstone and
21 Pete Domenici Mental Health Parity and Addiction Equity Act of
22 2008 to Medicaid managed care organizations, the Children's
23 Health Insurance Program, and alternative benefit plans.
24 (f) The provisions of subsections (b) and (c) of this
25 Section shall not be interpreted to allow the use of lifetime
26 or annual limits otherwise prohibited by State or federal law.
SB3365 Enrolled - 286 - LRB104 18483 SSS 31925 b
1 (g) As used in this Section:
2 "Financial requirement" includes deductibles, copayments,
3 coinsurance, and out-of-pocket maximums, but does not include
4 an aggregate lifetime limit or an annual limit subject to
5 subsections (b) and (c).
6 "Mental, emotional, nervous, or substance use disorder or
7 condition" means a condition or disorder that involves a
8 mental health condition or substance use disorder that falls
9 under any of the diagnostic categories listed in the mental
10 and behavioral disorders chapter of the current edition of the
11 International Classification of Disease or that is listed in
12 the most recent version of the Diagnostic and Statistical
13 Manual of Mental Disorders.
14 "Treatment limitation" includes limits on benefits based
15 on the frequency of treatment, number of visits, days of
16 coverage, days in a waiting period, or other similar limits on
17 the scope or duration of treatment. "Treatment limitation"
18 includes both quantitative treatment limitations, which are
19 expressed numerically (such as 50 outpatient visits per year),
20 and nonquantitative treatment limitations, which otherwise
21 limit the scope or duration of treatment. A permanent
22 exclusion of all benefits for a particular condition or
23 disorder shall not be considered a treatment limitation.
24 "Nonquantitative treatment limitations" means those
25 limitations as described under federal regulations (26 CFR
26 54.9812-1). "Nonquantitative treatment limitations" include,
SB3365 Enrolled - 287 - LRB104 18483 SSS 31925 b
1 but are not limited to, those limitations described under
2 federal regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45
3 CFR 146.136.
4 (h) The Department of Insurance shall implement the
5 following education initiatives:
6 (1) By January 1, 2016, the Department shall develop a
7 plan for a Consumer Education Campaign on parity. The
8 Consumer Education Campaign shall focus its efforts
9 throughout the State and include trainings in the
10 northern, southern, and central regions of the State, as
11 defined by the Department, as well as each of the 5 managed
12 care regions of the State as identified by the Department
13 of Healthcare and Family Services. Under this Consumer
14 Education Campaign, the Department shall: (1) by January
15 1, 2017, provide at least one live training in each region
16 on parity for consumers and providers and one webinar
17 training to be posted on the Department website and (2)
18 establish a consumer hotline to assist consumers in
19 navigating the parity process by March 1, 2017. By January
20 1, 2018 the Department shall issue a report to the General
21 Assembly on the success of the Consumer Education
22 Campaign, which shall indicate whether additional training
23 is necessary or would be recommended.
24 (2) (Blank).
25 (3) Not later than March January 1 of each year,
26 beginning in calendar year 2027, the Department, in
SB3365 Enrolled - 288 - LRB104 18483 SSS 31925 b
1 conjunction with the Department of Healthcare and Family
2 Services, shall issue a joint report to the General
3 Assembly. The joint report shall be posted on each
4 respective department's website and provide an educational
5 presentation to the General Assembly. The report and
6 presentation shall:
7 (A) Cover the methodology the Departments use to
8 check for compliance with the federal Paul Wellstone
9 and Pete Domenici Mental Health Parity and Addiction
10 Equity Act of 2008, 42 U.S.C. 18031(j), and any
11 federal regulations or guidance relating to the
12 compliance and oversight of the federal Paul Wellstone
13 and Pete Domenici Mental Health Parity and Addiction
14 Equity Act of 2008 and 42 U.S.C. 18031(j).
15 (B) Cover the methodology the Departments use to
16 check for compliance with this Section and Sections
17 356z.23 and 370c of this Code.
18 (C) Identify market conduct examinations or, in
19 the case of the Department of Healthcare and Family
20 Services, audits conducted or completed during the
21 preceding 12-month period regarding compliance with
22 parity in mental, emotional, nervous, and substance
23 use disorder or condition benefits under State and
24 federal laws and summarize the results of such market
25 conduct examinations and audits. This shall include:
26 (i) the number of market conduct examinations
SB3365 Enrolled - 289 - LRB104 18483 SSS 31925 b
1 and audits initiated and completed;
2 (ii) the benefit classifications examined by
3 each market conduct examination and audit;
4 (iii) the subject matter of each market
5 conduct examination and audit, including
6 quantitative and nonquantitative treatment
7 limitations; and
8 (iv) a summary of the basis for the final
9 decision rendered in each market conduct
10 examination and audit.
11 Individually identifiable information shall be
12 excluded from the reports consistent with federal
13 privacy protections.
14 (D) Detail any educational or corrective actions
15 the Departments have taken to ensure compliance with
16 the federal Paul Wellstone and Pete Domenici Mental
17 Health Parity and Addiction Equity Act of 2008, 42
18 U.S.C. 18031(j), this Section, and Sections 356z.23
19 and 370c of this Code.
20 (E) The report must be written in non-technical,
21 readily understandable language and shall be made
22 available to the public by, among such other means as
23 the Departments find appropriate, posting the report
24 on the Departments' websites.
25 (i) The Parity Advancement Fund is created as a special
26 fund in the State treasury. Moneys from fines and penalties
SB3365 Enrolled - 290 - LRB104 18483 SSS 31925 b
1 collected from insurers for violations of this Section shall
2 be deposited into the Fund. Moneys deposited into the Fund for
3 appropriation by the General Assembly to the Department shall
4 be used for the purpose of providing financial support of the
5 Consumer Education Campaign, parity compliance advocacy, and
6 other initiatives that support parity implementation and
7 enforcement on behalf of consumers.
8 (j) (Blank).
9 (j-5) The Department of Insurance shall collect the
10 following information:
11 (1) The number of employment disability insurance
12 plans offered in this State, including, but not limited
13 to:
14 (A) individual short-term policies;
15 (B) individual long-term policies;
16 (C) group short-term policies; and
17 (D) group long-term policies.
18 (2) The number of policies referenced in paragraph (1)
19 of this subsection that limit mental health and substance
20 use disorder benefits.
21 (3) The average defined benefit period for the
22 policies referenced in paragraph (1) of this subsection,
23 both for those policies that limit and those policies that
24 have no limitation on mental health and substance use
25 disorder benefits.
26 (4) Whether the policies referenced in paragraph (1)
SB3365 Enrolled - 291 - LRB104 18483 SSS 31925 b
1 of this subsection are purchased on a voluntary or
2 non-voluntary basis.
3 (5) The identities of the individuals, entities, or a
4 combination of the 2 that assume the cost associated with
5 covering the policies referenced in paragraph (1) of this
6 subsection.
7 (6) The average defined benefit period for plans that
8 cover physical disability and mental health and substance
9 abuse without limitation, including, but not limited to:
10 (A) individual short-term policies;
11 (B) individual long-term policies;
12 (C) group short-term policies; and
13 (D) group long-term policies.
14 (7) The average premiums for disability income
15 insurance issued in this State for:
16 (A) individual short-term policies that limit
17 mental health and substance use disorder benefits;
18 (B) individual long-term policies that limit
19 mental health and substance use disorder benefits;
20 (C) group short-term policies that limit mental
21 health and substance use disorder benefits;
22 (D) group long-term policies that limit mental
23 health and substance use disorder benefits;
24 (E) individual short-term policies that include
25 mental health and substance use disorder benefits
26 without limitation;
SB3365 Enrolled - 292 - LRB104 18483 SSS 31925 b
1 (F) individual long-term policies that include
2 mental health and substance use disorder benefits
3 without limitation;
4 (G) group short-term policies that include mental
5 health and substance use disorder benefits without
6 limitation; and
7 (H) group long-term policies that include mental
8 health and substance use disorder benefits without
9 limitation.
10 The Department shall present its findings regarding
11 information collected under this subsection (j-5) to the
12 General Assembly no later than April 30, 2024. Information
13 regarding a specific insurance provider's contributions to the
14 Department's report shall be exempt from disclosure under
15 paragraph (t) of subsection (1) of Section 7 of the Freedom of
16 Information Act. The aggregated information gathered by the
17 Department shall not be exempt from disclosure under paragraph
18 (t) of subsection (1) of Section 7 of the Freedom of
19 Information Act.
20 (k) An insurer that amends, delivers, issues, or renews a
21 group or individual policy of accident and health insurance or
22 a qualified health plan offered through the health insurance
23 marketplace in this State providing coverage for hospital or
24 medical treatment and for the treatment of mental, emotional,
25 nervous, or substance use disorders or conditions shall submit
26 an annual report, the format and definitions for which will be
SB3365 Enrolled - 293 - LRB104 18483 SSS 31925 b
1 determined by the Department and the Department of Healthcare
2 and Family Services and posted on their respective websites,
3 starting on September 1, 2023 and annually thereafter, that
4 contains the following information separately for inpatient
5 in-network benefits, inpatient out-of-network benefits,
6 outpatient in-network benefits, outpatient out-of-network
7 benefits, emergency care benefits, and prescription drug
8 benefits in the case of accident and health insurance or
9 qualified health plans, or inpatient, outpatient, emergency
10 care, and prescription drug benefits in the case of medical
11 assistance:
12 (1) A summary of the plan's pharmacy management
13 processes for mental, emotional, nervous, or substance use
14 disorder or condition benefits compared to those for other
15 medical benefits.
16 (2) A summary of the internal processes of review for
17 experimental benefits and unproven technology for mental,
18 emotional, nervous, or substance use disorder or condition
19 benefits and those for other medical benefits.
20 (3) A summary of how the plan's policies and
21 procedures for utilization management for mental,
22 emotional, nervous, or substance use disorder or condition
23 benefits compare to those for other medical benefits.
24 (4) A description of the process used to develop or
25 select the medical necessity criteria for mental,
26 emotional, nervous, or substance use disorder or condition
SB3365 Enrolled - 294 - LRB104 18483 SSS 31925 b
1 benefits and the process used to develop or select the
2 medical necessity criteria for medical and surgical
3 benefits.
4 (5) Identification of all nonquantitative treatment
5 limitations that are applied to both mental, emotional,
6 nervous, or substance use disorder or condition benefits
7 and medical and surgical benefits within each
8 classification of benefits.
9 (6) The results of an analysis that demonstrates that
10 for the medical necessity criteria described in
11 subparagraph (A) and for each nonquantitative treatment
12 limitation identified in subparagraph (B), as written and
13 in operation, the processes, strategies, evidentiary
14 standards, or other factors used in applying the medical
15 necessity criteria and each nonquantitative treatment
16 limitation to mental, emotional, nervous, or substance use
17 disorder or condition benefits within each classification
18 of benefits are comparable to, and are applied no more
19 stringently than, the processes, strategies, evidentiary
20 standards, or other factors used in applying the medical
21 necessity criteria and each nonquantitative treatment
22 limitation to medical and surgical benefits within the
23 corresponding classification of benefits; at a minimum,
24 the results of the analysis shall:
25 (A) identify the factors used to determine that a
26 nonquantitative treatment limitation applies to a
SB3365 Enrolled - 295 - LRB104 18483 SSS 31925 b
1 benefit, including factors that were considered but
2 rejected;
3 (B) identify and define the specific evidentiary
4 standards used to define the factors and any other
5 evidence relied upon in designing each nonquantitative
6 treatment limitation;
7 (C) provide the comparative analyses, including
8 the results of the analyses, performed to determine
9 that the processes and strategies used to design each
10 nonquantitative treatment limitation, as written, for
11 mental, emotional, nervous, or substance use disorder
12 or condition benefits are comparable to, and are
13 applied no more stringently than, the processes and
14 strategies used to design each nonquantitative
15 treatment limitation, as written, for medical and
16 surgical benefits;
17 (D) provide the comparative analyses, including
18 the results of the analyses, performed to determine
19 that the processes and strategies used to apply each
20 nonquantitative treatment limitation, in operation,
21 for mental, emotional, nervous, or substance use
22 disorder or condition benefits are comparable to, and
23 applied no more stringently than, the processes or
24 strategies used to apply each nonquantitative
25 treatment limitation, in operation, for medical and
26 surgical benefits; and
SB3365 Enrolled - 296 - LRB104 18483 SSS 31925 b
1 (E) disclose the specific findings and conclusions
2 reached by the insurer that the results of the
3 analyses described in subparagraphs (C) and (D)
4 indicate that the insurer is in compliance with this
5 Section and the Mental Health Parity and Addiction
6 Equity Act of 2008 and its implementing regulations,
7 which include includes 42 CFR Parts 438, 440, and 457
8 and 45 CFR 146.136 and any other related federal
9 regulations found in the Code of Federal Regulations.
10 (7) Any other information necessary to clarify data
11 provided in accordance with this Section requested by the
12 Director, including information that may be proprietary or
13 have commercial value, under the requirements of Section
14 30 of the Viatical Settlements Act of 2009.
15 (l) An insurer that amends, delivers, issues, or renews a
16 group or individual policy of accident and health insurance or
17 a qualified health plan offered through the health insurance
18 marketplace in this State providing coverage for hospital or
19 medical treatment and for the treatment of mental, emotional,
20 nervous, or substance use disorders or conditions on or after
21 January 1, 2019 (the effective date of Public Act 100-1024)
22 shall, in advance of the plan year, make available to the
23 Department or, with respect to medical assistance, the
24 Department of Healthcare and Family Services and to all plan
25 participants and beneficiaries the information required in
26 subparagraphs (C) through (E) of paragraph (6) of subsection
SB3365 Enrolled - 297 - LRB104 18483 SSS 31925 b
1 (k). For plan participants and medical assistance
2 beneficiaries, the information required in subparagraphs (C)
3 through (E) of paragraph (6) of subsection (k) shall be made
4 available on a publicly available website whose web address is
5 prominently displayed in plan and managed care organization
6 informational and marketing materials.
7 (m) In conjunction with its compliance examination program
8 conducted in accordance with the Illinois State Auditing Act,
9 the Auditor General shall undertake a review of compliance by
10 the Department and the Department of Healthcare and Family
11 Services with Section 370c and this Section. Any findings
12 resulting from the review conducted under this Section shall
13 be included in the applicable State agency's compliance
14 examination report. Each compliance examination report shall
15 be issued in accordance with Section 3-14 of the Illinois
16 State Auditing Act. A copy of each report shall also be
17 delivered to the head of the applicable State agency and
18 posted on the Auditor General's website.
19 (Source: P.A. 103-94, eff. 1-1-24; 103-105, eff. 6-27-23;
20 103-605, eff. 7-1-24; 104-334, eff. 8-15-25.)
21 ARTICLE 200.
22 Section 200-5. The Illinois Public Aid Code is amended by
23 changing Sections 5F-10, 5F-15, and 5F-35 as follows:
SB3365 Enrolled - 298 - LRB104 18483 SSS 31925 b
1 (305 ILCS 5/5F-10)
2 Sec. 5F-10. Scope. This Article applies to policies and
3 contracts amended, delivered, issued, or renewed on or after
4 the effective date of this amendatory Act of the 98th General
5 Assembly for the nursing home component of the
6 Medicare-Medicaid Alignment Initiative and the Managed
7 Long-Term Services and Support Program, a fully integrated
8 dual eligible special needs plan, or any managed care plan for
9 persons who are dually eligible for Medicare and Medicaid.
10 This Article does not diminish a managed care organization's
11 duties and responsibilities under other federal or State laws
12 or rules adopted under those laws and the 3-way
13 Medicare-Medicaid Alignment Initiative contract and the
14 Managed Long-Term Services and Support Program contract.
15 (Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
16 (305 ILCS 5/5F-15)
17 Sec. 5F-15. Definitions. As used in this Article:
18 "Appeal" means any of the procedures that deal with the
19 review of adverse organization determinations on the health
20 care services the enrollee believes he or she is entitled to
21 receive, including delay in providing, arranging for, or
22 approving the health care services, such that a delay would
23 adversely affect the health of the enrollee or on any amounts
24 the enrollee must pay for a service, as defined under 42 CFR
25 422.566(b). These procedures include reconsiderations by the
SB3365 Enrolled - 299 - LRB104 18483 SSS 31925 b
1 managed care organization and, if necessary, an independent
2 review entity as provided by the Health Carrier External
3 Review Act, hearings before administrative law judges, review
4 by the Medicare Appeals Council, and judicial review.
5 "Demonstration Project" means the nursing home component
6 of the Medicare-Medicaid Alignment Initiative Demonstration
7 Project, a fully integrated dual eligible special needs plan,
8 or any managed care plan for persons who are dually eligible
9 for Medicare and Medicaid.
10 "Department" means the Department of Healthcare and Family
11 Services.
12 "Enrollee" means an individual who resides in a nursing
13 home or is qualified to be admitted to a nursing home and is
14 enrolled with a managed care organization participating in the
15 Demonstration Project.
16 "Health care services" means the diagnosis, treatment, and
17 prevention of disease and includes medication, primary care,
18 nursing or medical care, mental health treatment, psychiatric
19 rehabilitation, memory loss services, physical, occupational,
20 and speech rehabilitation, enhanced care, medical supplies and
21 equipment and the repair of such equipment, and assistance
22 with activities of daily living.
23 "Managed care organization" or "MCO" means an entity that
24 meets the definition of health maintenance organization as
25 defined in the Health Maintenance Organization Act, is
26 licensed, regulated and in good standing with the Department
SB3365 Enrolled - 300 - LRB104 18483 SSS 31925 b
1 of Insurance, and is authorized to participate in the nursing
2 home component of the Medicare-Medicaid Alignment Initiative
3 Demonstration Project by a 3-way contract with the Department
4 of Healthcare and Family Services and the Centers for Medicare
5 and Medicaid Services.
6 "Medical professional" means a physician, physician
7 assistant, or nurse practitioner.
8 "Medically necessary" means health care services that a
9 medical professional, exercising prudent clinical judgment,
10 would provide to a patient for the purpose of preventing,
11 evaluating, diagnosing, or treating an illness, injury, or
12 disease or its symptoms, and that are: (i) in accordance with
13 the generally accepted standards of medical practice; (ii)
14 clinically appropriate, in terms of type, frequency, extent,
15 site, and duration, and considered effective for the patient's
16 illness, injury, or disease; and (iii) not primarily for the
17 convenience of the patient, a medical professional, other
18 health care provider, caregiver, family member, or other
19 interested party.
20 "Nursing home" means a facility licensed under the Nursing
21 Home Care Act.
22 "Nurse practitioner" means an individual properly licensed
23 as a nurse practitioner under the Nurse Practice Act.
24 "Physician" means an individual licensed to practice in
25 all branches of medicine under the Medical Practice Act of
26 1987.
SB3365 Enrolled - 301 - LRB104 18483 SSS 31925 b
1 "Physician assistant" means an individual properly
2 licensed under the Physician Assistant Practice Act of 1987.
3 "Resident" means an enrollee who is receiving personal or
4 medical care, including, but not limited to, mental health
5 treatment, psychiatric rehabilitation, physical
6 rehabilitation, and assistance with activities of daily
7 living, from a nursing home.
8 "RAI Manual" means the most recent Resident Assessment
9 Instrument Manual, published by the Centers for Medicare and
10 Medicaid Services.
11 "Resident's representative" means a person designated in
12 writing by a resident to be the resident's representative or
13 the resident's guardian, as described by the Nursing Home Care
14 Act.
15 "SNFist" means a medical professional specializing in the
16 care of individuals residing in nursing homes employed by or
17 under contract with an a MCO.
18 "Transition period" means a period of time immediately
19 following enrollment into the Demonstration Project or an
20 enrollee's movement from one managed care organization to
21 another managed care organization or one care setting to
22 another care setting.
23 (Source: P.A. 98-651, eff. 6-16-14.)
24 (305 ILCS 5/5F-35)
25 Sec. 5F-35. Reimbursement. The Department shall provide
SB3365 Enrolled - 302 - LRB104 18483 SSS 31925 b
1 each managed care organization with the quarterly
2 facility-specific RUG-IV nursing component per diem along with
3 any add-ons for enhanced care services, support component per
4 diem, and capital component per diem effective for each
5 nursing home under contract with the managed care
6 organization.
7 (Source: P.A. 98-651, eff. 6-16-14.)
8 ARTICLE 210.
9 Section 210-5. The Nursing Home Care Act is amended by
10 adding Article IIIB as follows:
11 (210 ILCS 45/Art. IIIB heading new)
12 ARTICLE IIIB. COTTAGE STYLE NURSING HOMES
13 (210 ILCS 45/3B-100 new)
14 Sec. 3B-100. Definitions. As used in this Article:
15 "Clinical support team" (CST) means non-universal team
16 members who provide support services throughout the campus.
17 The CST provides support to self-directed or self-managed work
18 teams. The CST includes, but is not limited to, the
19 Administrator, Director of Nursing, Assistant Director of
20 Nursing, and Minimum Data Set nurse.
21 "Cottage style" or "cottage style facilities" means small,
22 free-standing, self-contained homes that:
SB3365 Enrolled - 303 - LRB104 18483 SSS 31925 b
1 (1) Surround or are adjacent to a central
2 administration unit.
3 (2) Provide up to 12 private residents' rooms that are
4 shared only at the request of a resident to accommodate a
5 spouse, partner, or family member. A spouse that does not
6 meet medical criteria for nursing facility placement may
7 reside in the room assigned to a spouse who is admitted to
8 the facility and who meets medical criteria for admission.
9 The facility may charge the spouse who does not meet
10 medical criteria for room and board, as well as other
11 services so long as the facility meets all requirements or
12 cost reporting.
13 (3) Have a full, accessible private bathroom for each
14 resident room that contains, at a minimum, a toilet, sink,
15 and shower.
16 (4) Have the appearance of a residential dwelling for
17 both the exterior and the interior.
18 (5) Have residents' rooms constructed around a
19 central, communal, family-style open space that includes a
20 hearth room, dining area, and residential-style kitchen.
21 The central communal area shall contain a living area
22 where residents and staff may socialize, dine, and prepare
23 food together that, at a minimum, provides a living room
24 seating area, a dining area large enough for a single
25 table serving all residents in the home plus 2 staff
26 members, and an open full kitchen. The communal area may
SB3365 Enrolled - 304 - LRB104 18483 SSS 31925 b
1 include a gas fireplace with a fixed, "stay-cool" glass
2 screen.
3 (6) Have all residents' room entrances visible from
4 the central communal area.
5 (7) Each communal area may not exceed a ratio of one
6 communal area to 12 resident rooms.
7 (8) Two cottages may share a centralized kitchen and
8 laundry, but each may not exceed a ratio of one
9 kitchen/laundry to 24 resident rooms.
10 (9) Contains residential-style design approach, scale,
11 details, and materials throughout the home that are
12 similar to the typical residential designs and finishes in
13 the immediate surrounding community and does not contain
14 or utilize commercial and institutional elements and
15 products such as a nurse station, medication carts,
16 hospital or office type fluorescent lighting, acoustical
17 tile ceilings, institutional-style railings, room
18 numbering, and labeling and signage that would not
19 normally be found in a private home setting.
20 Where rules require specific institutional elements,
21 every effort shall be made to provide the institutional
22 elements in a manner consistent with what might be found
23 in a new private home in the community (such as
24 residential wall sconces used for required nurse call
25 lights).
26 (10) Have outdoor space that:
SB3365 Enrolled - 305 - LRB104 18483 SSS 31925 b
1 (A) allows residents to ambulate, with or without
2 assistive devices such as wheelchairs or walkers;
3 (B) signals staff wirelessly when someone enters
4 the outdoor space from the cottage style home;
5 (C) is partially covered to protect from sun and
6 elements under the covered area; and
7 (D) provides for outdoor activities.
8 (11) Utilize a wireless alert or call system. The
9 system shall also include, for residents who have been
10 care planned to be at risk for wandering or elopement,
11 location bracelets that permit residents to signal for
12 assistance and enable staff to locate residents. Wired
13 call or alert systems and overhead paging are not
14 permitted.
15 (12) Utilize a wireless communication and notification
16 system for staff. The system shall provide a means for
17 notification of staff both in the home and in other homes
18 or other areas of the facility occupied by other staff.
19 (13) Contain ample natural light in each habitable
20 space provided through exterior windows and other means,
21 with window areas, exclusive of skylights and
22 clerestories, being a minimum of 10% of the area of the
23 room.
24 (14) Have built-in safety features (such as magnetic
25 locks on cabinets with chemicals or knives) to allow all
26 areas of the house, including the kitchen and any staff
SB3365 Enrolled - 306 - LRB104 18483 SSS 31925 b
1 office, to be accessible to the residents during the
2 majority of the day and night.
3 (15) Provide self-directed care for residents through
4 the establishment of self-managed or self-directed work
5 teams consisting of certified nursing assistants.
6 (16) Prepare and cook at least 80% of resident meals
7 in the cottage style home. Nothing in this item (16)
8 prohibits the consumption of foods that are:
9 (A) prepared outside the cottage style home by
10 family, acquaintances, or social organizations such as
11 churches;
12 (B) grown in or on the grounds of the cottage style
13 home by residents or staff; or
14 (C) prepared by local retail eating establishments
15 that are licensed or inspected based on local, State,
16 or federal laws.
17 (17) Train all staff involved in the operation of the
18 project in the philosophy, operations, and skills required
19 to implement and maintain self-directed care,
20 self-directed or self-managed work teams, a
21 non-institutional approach to life and care in long-term
22 care, appropriate safety and emergency skills, and other
23 elements required for successful operations and outcomes
24 of the project.
25 (18) Are designed to be fully accessible for persons
26 with disabilities.
SB3365 Enrolled - 307 - LRB104 18483 SSS 31925 b
1 (19) Have overhead lift tracks that run from the bed
2 into the bathroom in at least 30% of resident rooms.
3 (20) Have at least one lift motor for each cottage
4 style home.
5 (21) Have separate slings for each resident in the
6 facility who requires a lift.
7 (22) Are not connected to, or share, any area that
8 would not typically be connected or shared between private
9 homes in the surrounding community (such as a driveway).
10 (23) Provide the necessary care and services to attain
11 or maintain the highest practicable physical, mental, and
12 psychological well-being of the resident, in accordance
13 with each resident's comprehensive resident care plan.
14 (24) Maintain a staffing plan compliant with the
15 minimum direct care staffing ratios required by this Act,
16 the Illinois Administrative Code, and any other applicable
17 State or federal law.
18 (25) Maintain all professional licensure for staff and
19 employees in accordance with applicable State laws,
20 including, but not limited to, Department of Financial and
21 Professional Regulation requirements.
22 (26) Comply with any applicable State and federal
23 consent decrees.
24 (27) Obtain proof and documentation of federal
25 approval by the Centers for Medicare and Medicaid
26 Services.
SB3365 Enrolled - 308 - LRB104 18483 SSS 31925 b
1 "Home" means each discrete cottage style unit housing up
2 to 12 private residents' rooms.
3 "Person-directed care" means a holistic model that takes
4 into consideration each resident's physical, mental, and
5 social needs in the development of a care and treatment plan
6 and the delivery of services that is driven to the greatest
7 extent possible by resident choice, as opposed to an
8 institutional medical model that is schedule and task driven.
9 "Self-managed or self-directed work team" means the
10 universal workers assigned to a specific cottage style home
11 and who determine, plan, and manage day-to-day activities in
12 the house with little or no direct supervision.
13 "Food safety" means a method of ensuring safe preparation
14 and delivery of food for and to residents.
15 "Family-style dining" means residential-style dining, in
16 which all food is placed in serving bowls, platters, and
17 similar residential serving dishes on the table, residents and
18 staff dine together, and residents are encouraged to serve
19 themselves or serve themselves with help from staff.
20 "Universal or flexible worker" means a certified nursing
21 assistant who has received additional training in the areas of
22 dietary, housekeeping, activities, and laundry and is a member
23 of the self-managed or self-directed work team.
24 (210 ILCS 45/3B-105 new)
25 Sec. 3B-105. Intent. This Article creates a framework that
SB3365 Enrolled - 309 - LRB104 18483 SSS 31925 b
1 encourages the construction and operation of skilled nursing
2 facilities that are consistent with State and federal laws and
3 referred to as "cottage style". The cottage style model is a
4 facility model resulting in a residential-style physical plant
5 and specific principles of staff interaction. The cottage
6 style model utilizes small, free-standing, self-contained
7 homes. A single cottage consists of up to 12 private rooms,
8 each with full bathrooms. Two cottages may share a common
9 kitchen and laundry but the maximum ratio of 1 kitchen and
10 laundry per 24 rooms must be maintained. The residents' rooms
11 are constructed around a central, communal, family-style open
12 space that includes a hearth room and dining area. All
13 residents' room entrances are visible from the central
14 communal area. The maximum ratio of one communal area per 12
15 rooms must be maintained. Each home is built to blend
16 architecturally with neighboring homes.
17 (210 ILCS 45/3B-110 new)
18 Sec. 3B-110. Applicability. Nursing homes that meet the
19 requirements of this Article to be designated as a cottage
20 style nursing home are still subject to all requirements of
21 this Act, administrative rules, and applicable State or
22 federal laws. All requirements of this Article are additional
23 requirements necessary to be designated as cottage style as
24 defined in Section 3B-100.
SB3365 Enrolled - 310 - LRB104 18483 SSS 31925 b
1 (210 ILCS 45/3B-115 new)
2 Sec. 3B-115. License designation. During the initial
3 licensure survey required under Section 3-109 of this Act, the
4 Department must also review compliance with this Article. The
5 Department must indicate, on licenses issued under this Act,
6 "cottage style" for nursing homes that meet the requirements
7 of this Article.
8 (210 ILCS 45/3B-120 new)
9 Sec. 3B-120. Staff Training.
10 (a) In addition to any State or federal training
11 requirements pertaining to long-term care facilities, each
12 certified nursing assistant (CNA) working in a cottage style
13 home shall complete the following 40 hours of training, to
14 include, but not be limited to:
15 (1) Cottage Style Model v. Traditional Model, a
16 minimum of 2 hours covering at least the following topics:
17 (A) Meaningful Engagement. Development of, and
18 appreciation for, activities designed to meet the
19 individual's personal preferences and needs.
20 (B) Organizational Culture Change.
21 (2) Universal or Flexible Worker, a minimum of 2 hours
22 covering at least the following topics:
23 (A) Concept.
24 (B) Responsibilities of the Worker.
25 (3) Person-Directed Care, a minimum of 2 hours
SB3365 Enrolled - 311 - LRB104 18483 SSS 31925 b
1 covering at least the following topics:
2 (A) Concepts and Relationship Building.
3 (B) Execution. How elder preferences shape
4 workflow.
5 (4) Self-Managed or Self-Directed Work Team, a minimum
6 of 4 hours covering at least the following topics:
7 (A) Concept.
8 (B) Responsibilities.
9 (C) Conflict Resolution and Learning Circles.
10 (5) Food Safety, a minimum of 22 hours covering at
11 least the following topics:
12 (A) Safety.
13 (B) Contamination.
14 (C) Allergies.
15 (D) Therapeutic Diets.
16 (E) Thickening Agents.
17 (F) Food Preparation.
18 (G) Family Style Dining.
19 (H) Cottage Equipment Use. Appliance usage and
20 safety.
21 (6) Emergency Situations and Evacuation, a minimum of
22 2 hours covering at least the following topics:
23 (A) Fire Drills.
24 (B) Tornado Drills.
25 (C) Disaster Drills.
26 (D) Evacuation.
SB3365 Enrolled - 312 - LRB104 18483 SSS 31925 b
1 (E) Environmental Policy.
2 (7) Cottage Orientation, a minimum of 2 hours covering
3 at least the following topics:
4 (A) Phone System.
5 (B) Call System.
6 (C) Cleaning Supply Storage.
7 (D) Cleaning Supply Usage.
8 (E) Workplace Organization.
9 (8) Communication, a minimum of 2 hours covering at
10 least the following topics:
11 (A) Communication Skills.
12 (B) Coaching Skills.
13 (C) Accountability.
14 (D) Support.
15 (9) Observation Skills, a minimum of 2 hours covering
16 at least the following topics:
17 (A) How to obtain a history from family.
18 (B) How to modify a care plan.
19 (C) How to identify a resident's change in
20 condition.
21 (b) Upon opening and for the first 90 days of continuous
22 operation of a cottage style home, all CNAs working in that
23 home shall complete all of the required training listed in
24 subsection (a) prior to providing services in the cottage
25 style home.
26 (c) After a cottage style home has been in continuous
SB3365 Enrolled - 313 - LRB104 18483 SSS 31925 b
1 operation servicing residents for at least 90 days, each CNA
2 assigned to the cottage style home for the first time, and who
3 has not been trained in accordance with subsections (a) and
4 (b), shall complete the following 16-hour training schedule
5 before working with residents:
6 (1) Cottage Style Model v. Traditional Model, a
7 minimum of 1.5 hours.
8 (2) Universal or Flexible Worker, a minimum of 1.5
9 hours.
10 (3) Person-Directed Care, a minimum of 3 hours.
11 (4) Self-Managed or Self-Directed Work Team, a minimum
12 of 3 hours.
13 (5) Food Safety, a minimum of 3 hours.
14 (6) Family Style Dining, a minimum of one hour.
15 (7) Emergency Situations and Evacuations, a minimum of
16 one hour.
17 (8) Cottage Equipment Use, a minimum of one hour.
18 (9) Cottage Orientation, a minimum of one hour.
19 Following the 16-hour training the CNA shall complete the
20 remaining 24 hours of training listed in subsection (a) within
21 90 days.
22 (d) All shared common staff shall undergo the following
23 training within 45 days of the opening of the first cottage
24 style home:
25 (1) Cottage Style Model v. Traditional Model, a
26 minimum of 1.5 hours.
SB3365 Enrolled - 314 - LRB104 18483 SSS 31925 b
1 (2) Clinical Support Team, a minimum of one hour.
2 (3) Universal or Flexible Worker, a minimum of one
3 hour.
4 (4) Self-Managed or Self-Directed Work Team, a minimum
5 of 3 hours.
6 (5) Person-Directed Care, a minimum of 3 hours.
7 (6) Team Communication, a minimum of one hour.
8 (7) Learning Circles, a minimum of one hour.
9 (8) Understanding Aging in the Elderly, a minimum of
10 one hour.
11 (9) Cottage Systems, a minimum of 2 hours.
12 (e) Each facility seeking designation as a cottage style
13 facility shall provide to the Department a syllabus, a list of
14 required reference and study materials, and a proposed
15 curriculum of training as required under this Section. As used
16 in this Section, "curriculum" means a detailed study guide
17 that states the learning objectives and provides information
18 or materials designed to impart to the student or trainee the
19 necessary skills, knowledge, or ability required under the
20 learning objectives.
21 (f) Facilities must keep all trainings current with all
22 changes in best practices and local, State, and federal laws,
23 rules, regulations, and guidance.
24 (210 ILCS 45/3B-125 new)
25 Sec. 3B-125. Implementation. The Department may adopt
SB3365 Enrolled - 315 - LRB104 18483 SSS 31925 b
1 administrative rules to implement any part of this Article;
2 however, all provisions of this Article are fully effective
3 upon taking effect even if administrative rules have not been
4 adopted.
5 Section 210-10. The Illinois Public Aid Code is amended by
6 adding Section 5-5.2a as follows:
7 (305 ILCS 5/5-5.2a new)
8 Sec. 5-5.2a. Cottage style nursing home reimbursement
9 adjustment.
10 (a) As used in this Section, "cottage style nursing home"
11 means a nursing home meeting the requirements under Article
12 IIIB of the Nursing Home Care Act.
13 (b) Subject to any necessary federal approval, for dates
14 of service on and after July 1, 2027, the Department shall
15 reimburse cottage style nursing homes with a per diem add-on
16 of at least $50.
17 (c) This per diem add-on amount is in addition to all
18 amounts reimbursed to a nursing home under this Code. To
19 account for the unique person-directed care model in cottage
20 style nursing homes, the Department may increase the initial
21 default rates of a new cottage style nursing home until data
22 required to calculate those rates are available.
23 ARTICLE 215.
SB3365 Enrolled - 316 - LRB104 18483 SSS 31925 b
1 Section 215-5. The Illinois Public Aid Code is amended by
2 changing Section 5-5e.1 as follows:
3 (305 ILCS 5/5-5e.1)
4 Sec. 5-5e.1. Safety-Net Hospitals.
5 (a) A Safety-Net Hospital is an Illinois hospital that:
6 (1) is licensed by the Department of Public Health as
7 a general acute care or pediatric hospital; and
8 (2) is a disproportionate share hospital, as described
9 in Section 1923 of the federal Social Security Act, as
10 determined by the Department; and
11 (3) meets one of the following:
12 (A) has a MIUR of at least 40% and a charity
13 percent of at least 4%; or
14 (B) has a MIUR of at least 50%.
15 (b) Definitions. As used in this Section:
16 (1) "Charity percent" means the ratio of (i) the
17 hospital's charity charges for services provided to
18 individuals without health insurance or another source of
19 third party coverage to (ii) the Illinois total hospital
20 charges, each as reported on the hospital's OBRA form.
21 (2) "MIUR" means Medicaid Inpatient Utilization Rate
22 and is defined as a fraction, the numerator of which is the
23 number of a hospital's inpatient days provided in the
24 hospital's fiscal year ending 3 years prior to the rate
SB3365 Enrolled - 317 - LRB104 18483 SSS 31925 b
1 year, to patients who, for such days, were eligible for
2 Medicaid under Title XIX of the federal Social Security
3 Act, 42 USC 1396a et seq., excluding those persons
4 eligible for medical assistance pursuant to 42 U.S.C.
5 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
6 Section 5-2 of this Article, and the denominator of which
7 is the total number of the hospital's inpatient days in
8 that same period, excluding those persons eligible for
9 medical assistance pursuant to 42 U.S.C.
10 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
11 Section 5-2 of this Article.
12 (3) "OBRA form" means form HFS-3834, OBRA '93 data
13 collection form, for the rate year.
14 (4) "Rate year" means the 12-month period beginning on
15 October 1.
16 (c) Beginning July 1, 2012 and ending on December 31, 2028
17 2026, a hospital that would have qualified for the rate year
18 beginning October 1, 2011 or October 1, 2012 shall be a
19 Safety-Net Hospital.
20 (c-5) Beginning July 1, 2020 and ending on December 31,
21 2028 2026, a hospital that would have qualified for the rate
22 year beginning October 1, 2020 and was designated a federal
23 rural referral center under 42 CFR 412.96 as of October 1, 2020
24 shall be a Safety-Net Hospital.
25 (d) No later than August 15 preceding the rate year, each
26 hospital shall submit the OBRA form to the Department. Prior
SB3365 Enrolled - 318 - LRB104 18483 SSS 31925 b
1 to October 1, the Department shall notify each hospital
2 whether it has qualified as a Safety-Net Hospital.
3 (e) The Department may promulgate rules in order to
4 implement this Section.
5 (f) Nothing in this Section shall be construed as limiting
6 the ability of the Department to include the Safety-Net
7 Hospitals in the hospital rate reform mandated by Section
8 14-11 of this Code and implemented under Section 14-12 of this
9 Code and by administrative rulemaking.
10 (Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
11 102-886, eff. 5-17-22.)
12 ARTICLE 220.
13 Section 220-5. The Illinois Administrative Procedure Act
14 is amended by adding Section 5-45.72 as follows:
15 (5 ILCS 100/5-45.72 new)
16 Sec. 5-45.72. Emergency rulemaking; Department of
17 Healthcare and Family Services. In order to provide for the
18 expeditious and timely implementation of the federal Medicaid
19 provisions contained in Public Law 119-21, including all
20 corresponding federal regulations and requirements issued by
21 the federal Centers for Medicare and Medicaid Services, the
22 Department of Healthcare and Family Services may adopt
23 emergency rules during fiscal year 2027. Emergency rulemaking
SB3365 Enrolled - 319 - LRB104 18483 SSS 31925 b
1 authority will pertain to changes in Public Law 119-21 with
2 implementation dates on or before January 1, 2027, which are
3 addressed in this amendatory Act of the 104th General
4 Assembly. During the 12-month period in which this Section is
5 in effect, the 24-month limitation on the adoption of
6 emergency rules does not apply to the rules adopted under this
7 subsection if such an amendment is due to subsequent federal
8 guidance or other federal requirements pertaining to changes
9 in federal law or regulation. The adoption of emergency rules
10 authorized by this Section shall be deemed to be necessary for
11 the public interest, safety, and welfare.
12 This Section is repealed one year after the effective date
13 of this amendatory Act of the 104th General Assembly.
14 Section 220-10. The Illinois Public Aid Code is amended by
15 changing Sections 1-11, 5-2, 5-2.1d, 11-4, 11-5.1, and 11-5.4
16 as follows:
17 (305 ILCS 5/1-11)
18 Sec. 1-11. Citizenship. To the extent not otherwise
19 provided in this Code or federal law, all clients who receive
20 cash or medical assistance under Article III, IV, V, or VI of
21 this Code must meet the citizenship requirements as
22 established in this Section. To be eligible for assistance an
23 individual, who is otherwise eligible, must be either a United
24 States citizen or included in one of the following categories
SB3365 Enrolled - 320 - LRB104 18483 SSS 31925 b
1 of non-citizens:
2 (1) United States veterans honorably discharged and
3 persons on active military duty, and the spouse and
4 unmarried dependent children of these persons;
5 (2) Refugees under Section 207 of the Immigration and
6 Nationality Act;
7 (3) Asylees under Section 208 of the Immigration and
8 Nationality Act;
9 (4) Persons for whom deportation has been withheld
10 under Section 243(h) of the Immigration and Nationality
11 Act;
12 (5) Persons granted conditional entry under Section
13 203(a)(7) of the Immigration and Nationality Act as in
14 effect prior to April 1, 1980;
15 (6) Persons lawfully admitted for permanent residence
16 under the Immigration and Nationality Act;
17 (7) Parolees, for at least one year, under Section
18 212(d)(5) of the Immigration and Nationality Act;
19 (8) Nationals of Cuba or Haiti admitted on or after
20 April 21, 1980;
21 (9) Amerasians from Vietnam, and their close family
22 members, admitted through the Orderly Departure Program
23 beginning on March 20, 1988;
24 (10) Persons identified by the federal Office of
25 Refugee Resettlement (ORR) as victims of trafficking;
26 (11) Persons legally residing in the United States who
SB3365 Enrolled - 321 - LRB104 18483 SSS 31925 b
1 were members of a Hmong or Highland Laotian tribe when the
2 tribe helped United States personnel by taking part in a
3 military or rescue operation during the Vietnam era
4 (between August 5, 1965 and May 7, 1975); this also
5 includes the person's spouse, a widow or widower who has
6 not remarried, and unmarried dependent children;
7 (12) American Indians born in Canada under Section 289
8 of the Immigration and Nationality Act and members of an
9 Indian tribe as defined in Section 4e of the Indian
10 Self-Determination and Education Assistance Act;
11 (13) Persons who are a spouse, widow, or child of a
12 U.S. citizen or a spouse or child of a legal permanent
13 resident (LPR) who have been battered or subjected to
14 extreme cruelty by the U.S. citizen or LPR or a member of
15 that relative's family who lived with them, who no longer
16 live with the abuser or plan to live separately within one
17 month of receipt of assistance and whose need for
18 assistance is due, at least in part, to the abuse; and
19 (14) Persons who are foreign-born victims of
20 trafficking, torture, or other serious crimes as defined
21 in Section 2-19 of this Code.
22 Those persons who are in the categories set forth in
23 paragraphs subdivisions (6) and (7) of this Section, who enter
24 the United States on or after August 22, 1996, shall not be
25 eligible for 5 years beginning on the date the person entered
26 the United States.
SB3365 Enrolled - 322 - LRB104 18483 SSS 31925 b
1 The Illinois Department may, by rule, cover prenatal care
2 or emergency medical care for non-citizens who are not
3 otherwise eligible under this Section. Local governmental
4 units which do not receive State funds may impose their own
5 citizenship requirements and are authorized to provide any
6 benefits and impose any citizenship requirements as are
7 allowed under the Personal Responsibility and Work Opportunity
8 Reconciliation Act of 1996 (P.L. 104-193).
9 In order to implement the federal Medicaid provisions
10 contained in Public Law 119-21, and notwithstanding any other
11 provision of this Section, any category of non-citizens or
12 part thereof listed in paragraphs (1) through (14) of this
13 Section shall not be eligible for medical assistance under
14 Article V of this Code to the extent Public Law 119-21 and any
15 corresponding federal regulations or requirements issued by
16 the federal Centers for Medicare and Medicaid Services
17 excludes such category of non-citizens or part thereof from
18 eligibility, federal financial participation, or other federal
19 funding. This Section shall not require any category of
20 non-citizens or part thereof to be funded at state-only cost
21 under Article V of this Code, unless otherwise provided by
22 State law. The Department shall amend 89 Ill. Adm. Code
23 120.310 to conform to the provisions of this paragraph
24 effective October 1, 2026.
25 (Source: P.A. 99-870, eff. 8-22-16.)
SB3365 Enrolled - 323 - LRB104 18483 SSS 31925 b
1 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
2 Sec. 5-2. Classes of persons eligible. Medical assistance
3 under this Article shall be available to any of the following
4 classes of persons in respect to whom a plan for coverage has
5 been submitted to the Governor by the Illinois Department and
6 approved by him. If changes made in this Section 5-2 require
7 federal approval, they shall not take effect until such
8 approval has been received:
9 1. Recipients of basic maintenance grants under
10 Articles III and IV.
11 2. Beginning January 1, 2014, persons otherwise
12 eligible for basic maintenance under Article III,
13 excluding any eligibility requirements that are
14 inconsistent with any federal law or federal regulation,
15 as interpreted by the U.S. Department of Health and Human
16 Services, but who fail to qualify thereunder on the basis
17 of need, and who have insufficient income and resources to
18 meet the costs of necessary medical care, including, but
19 not limited to, the following:
20 (a) All persons otherwise eligible for basic
21 maintenance under Article III but who fail to qualify
22 under that Article on the basis of need and who meet
23 either of the following requirements:
24 (i) their income, as determined by the
25 Illinois Department in accordance with any federal
26 requirements, is equal to or less than 100% of the
SB3365 Enrolled - 324 - LRB104 18483 SSS 31925 b
1 federal poverty level; or
2 (ii) their income, after the deduction of
3 costs incurred for medical care and for other
4 types of remedial care, is equal to or less than
5 100% of the federal poverty level.
6 (b) (Blank).
7 3. (Blank).
8 4. Persons not eligible under any of the preceding
9 paragraphs who fall sick, are injured, or die, not having
10 sufficient money, property or other resources to meet the
11 costs of necessary medical care or funeral and burial
12 expenses.
13 5.(a) Beginning January 1, 2020, individuals during
14 pregnancy and during the 12-month period beginning on the
15 last day of the pregnancy, together with their infants,
16 whose income is at or below 200% of the federal poverty
17 level. Until September 30, 2019, or sooner if the
18 maintenance of effort requirements under the Patient
19 Protection and Affordable Care Act are eliminated or may
20 be waived before then, individuals during pregnancy and
21 during the 12-month period beginning on the last day of
22 the pregnancy, whose countable monthly income, after the
23 deduction of costs incurred for medical care and for other
24 types of remedial care as specified in administrative
25 rule, is equal to or less than the Medical Assistance-No
26 Grant(C) (MANG(C)) Income Standard in effect on April 1,
SB3365 Enrolled - 325 - LRB104 18483 SSS 31925 b
1 2013 as set forth in administrative rule.
2 (b) The plan for coverage shall provide ambulatory
3 prenatal care to pregnant individuals during a presumptive
4 eligibility period and establish an income eligibility
5 standard that is equal to 200% of the federal poverty
6 level, provided that costs incurred for medical care are
7 not taken into account in determining such income
8 eligibility.
9 (c) The Illinois Department may conduct a
10 demonstration in at least one county that will provide
11 medical assistance to pregnant individuals together with
12 their infants and children up to one year of age, where the
13 income eligibility standard is set up to 185% of the
14 nonfarm income official poverty line, as defined by the
15 federal Office of Management and Budget. The Illinois
16 Department shall seek and obtain necessary authorization
17 provided under federal law to implement such a
18 demonstration. Such demonstration may establish resource
19 standards that are not more restrictive than those
20 established under Article IV of this Code.
21 6. (a) Subject to federal approval, children younger
22 than age 19 when countable income is at or below 313% of
23 the federal poverty level, as determined by the Department
24 and in accordance with all applicable federal
25 requirements. The Department is authorized to adopt
26 emergency rules to implement the changes made to this
SB3365 Enrolled - 326 - LRB104 18483 SSS 31925 b
1 paragraph by Public Act 102-43. Until September 30, 2019,
2 or sooner if the maintenance of effort requirements under
3 the Patient Protection and Affordable Care Act are
4 eliminated or may be waived before then, children younger
5 than age 19 whose countable monthly income, after the
6 deduction of costs incurred for medical care and for other
7 types of remedial care as specified in administrative
8 rule, is equal to or less than the Medical Assistance-No
9 Grant(C) (MANG(C)) Income Standard in effect on April 1,
10 2013 as set forth in administrative rule.
11 (b) Children and youth who are under temporary custody
12 or guardianship of the Department of Children and Family
13 Services or who receive financial assistance in support of
14 an adoption or guardianship placement from the Department
15 of Children and Family Services.
16 7. (Blank).
17 8. As required under federal law, persons who are
18 eligible for Transitional Medical Assistance as a result
19 of an increase in earnings or child or spousal support
20 received. The plan for coverage for this class of persons
21 shall:
22 (a) extend the medical assistance coverage to the
23 extent required by federal law; and
24 (b) offer persons who have initially received 6
25 months of the coverage provided in paragraph (a)
26 above, the option of receiving an additional 6 months
SB3365 Enrolled - 327 - LRB104 18483 SSS 31925 b
1 of coverage, subject to the following:
2 (i) such coverage shall be pursuant to
3 provisions of the federal Social Security Act;
4 (ii) such coverage shall include all services
5 covered under Illinois' State Medicaid Plan;
6 (iii) no premium shall be charged for such
7 coverage; and
8 (iv) such coverage shall be suspended in the
9 event of a person's failure without good cause to
10 file in a timely fashion reports required for this
11 coverage under the Social Security Act and
12 coverage shall be reinstated upon the filing of
13 such reports if the person remains otherwise
14 eligible.
15 9. Persons with acquired immunodeficiency syndrome
16 (AIDS) or with AIDS-related conditions with respect to
17 whom there has been a determination that but for home or
18 community-based services such individuals would require
19 the level of care provided in an inpatient hospital,
20 skilled nursing facility or intermediate care facility the
21 cost of which is reimbursed under this Article. Assistance
22 shall be provided to such persons to the maximum extent
23 permitted under Title XIX of the Federal Social Security
24 Act.
25 10. Participants in the long-term care insurance
26 partnership program established under the Illinois
SB3365 Enrolled - 328 - LRB104 18483 SSS 31925 b
1 Long-Term Care Partnership Program Act who meet the
2 qualifications for protection of resources described in
3 Section 15 of that Act.
4 11. Persons with disabilities who are employed and
5 eligible for Medicaid, pursuant to Section
6 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
7 subject to federal approval, persons with a medically
8 improved disability who are employed and eligible for
9 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
10 the Social Security Act, as provided by the Illinois
11 Department by rule. In establishing eligibility standards
12 under this paragraph 11, the Department shall, subject to
13 federal approval:
14 (a) set the income eligibility standard at not
15 lower than 350% of the federal poverty level;
16 (b) exempt retirement accounts that the person
17 cannot access without penalty before the age of 59
18 1/2, and medical savings accounts established pursuant
19 to 26 U.S.C. 220;
20 (c) allow non-exempt assets up to $25,000 as to
21 those assets accumulated during periods of eligibility
22 under this paragraph 11; and
23 (d) continue to apply subparagraphs (b) and (c) in
24 determining the eligibility of the person under this
25 Article even if the person loses eligibility under
26 this paragraph 11.
SB3365 Enrolled - 329 - LRB104 18483 SSS 31925 b
1 12. Subject to federal approval, persons who are
2 eligible for medical assistance coverage under applicable
3 provisions of the federal Social Security Act and the
4 federal Breast and Cervical Cancer Prevention and
5 Treatment Act of 2000. Those eligible persons are defined
6 to include, but not be limited to, the following persons:
7 (1) persons who have been screened for breast or
8 cervical cancer under the U.S. Centers for Disease
9 Control and Prevention Breast and Cervical Cancer
10 Program established under Title XV of the federal
11 Public Health Service Act in accordance with the
12 requirements of Section 1504 of that Act as
13 administered by the Illinois Department of Public
14 Health; and
15 (2) persons whose screenings under the above
16 program were funded in whole or in part by funds
17 appropriated to the Illinois Department of Public
18 Health for breast or cervical cancer screening.
19 "Medical assistance" under this paragraph 12 shall be
20 identical to the benefits provided under the State's
21 approved plan under Title XIX of the Social Security Act.
22 The Department must request federal approval of the
23 coverage under this paragraph 12 within 30 days after July
24 3, 2001 (the effective date of Public Act 92-47).
25 In addition to the persons who are eligible for
26 medical assistance pursuant to subparagraphs (1) and (2)
SB3365 Enrolled - 330 - LRB104 18483 SSS 31925 b
1 of this paragraph 12, and to be paid from funds
2 appropriated to the Department for its medical programs,
3 any uninsured person as defined by the Department in rules
4 residing in Illinois who is younger than 65 years of age,
5 who has been screened for breast and cervical cancer in
6 accordance with standards and procedures adopted by the
7 Department of Public Health for screening, and who is
8 referred to the Department by the Department of Public
9 Health as being in need of treatment for breast or
10 cervical cancer is eligible for medical assistance
11 benefits that are consistent with the benefits provided to
12 those persons described in subparagraphs (1) and (2).
13 Medical assistance coverage for the persons who are
14 eligible under the preceding sentence is not dependent on
15 federal approval, but federal moneys may be used to pay
16 for services provided under that coverage upon federal
17 approval.
18 13. Subject to appropriation and to federal approval,
19 persons living with HIV/AIDS who are not otherwise
20 eligible under this Article and who qualify for services
21 covered under Section 5-5.04 as provided by the Illinois
22 Department by rule.
23 14. Subject to the availability of funds for this
24 purpose, the Department may provide coverage under this
25 Article to persons who
26 (a) reside in Illinois;
SB3365 Enrolled - 331 - LRB104 18483 SSS 31925 b
1 (b) are not eligible under any of the preceding
2 paragraphs of this Section;
3 (c) meet the income guidelines of paragraph 2(a)
4 of this Section; and
5 (d) meet one of the following conditions:
6 (i) have filed an application for asylum
7 status under 8 U.S.C. 1158 that is pending with
8 the appropriate federal agency or have a pending
9 appeal of such an application before a court of
10 competent jurisdiction and are represented either
11 by counsel or by an advocate accredited by the
12 appropriate federal agency and employed by a
13 not-for-profit organization in regard to that
14 application or appeal;
15 (ii) are receiving services through a
16 federally funded torture treatment center;
17 (iii) have filed a pending application for T
18 nonimmigrant status pursuant to 8 U.S.C.
19 1101(a)(15)(T);
20 (iv) have filed a pending application for U
21 nonimmigrant status pursuant to 8 U.S.C.
22 1101(a)(15)(U); or
23 (v) have filed as a derivative family member
24 or are included in the application for item (i),
25 (iii), or (iv) as provided by Department rule.
26 Medical coverage under this paragraph 14 may be
SB3365 Enrolled - 332 - LRB104 18483 SSS 31925 b
1 provided for up to 24 continuous months from the initial
2 eligibility date so long as an individual continues to
3 satisfy the criteria of this paragraph 14. If an
4 individual has an application or appeal pending regarding
5 an application for asylum, T nonimmigrant status, or U
6 nonimmigrant status before the appropriate federal agency
7 for such applications or appeals, eligibility under this
8 paragraph 14 may be extended until a final decision is
9 rendered with respect to the application or appeal, except
10 that an individual who is approved for a U visa continues
11 to qualify for medical coverage under this paragraph 14 as
12 long as the individual meets all other eligibility
13 criteria. The Department shall adopt rules governing the
14 implementation of this paragraph 14.
15 15. Family Care Eligibility.
16 (a) On and after July 1, 2012, a parent or other
17 caretaker relative who is 19 years of age or older when
18 countable income is at or below 133% of the federal
19 poverty level. A person may not spend down to become
20 eligible under this paragraph 15.
21 (b) Eligibility shall be reviewed annually.
22 (c) (Blank).
23 (d) (Blank).
24 (e) (Blank).
25 (f) (Blank).
26 (g) (Blank).
SB3365 Enrolled - 333 - LRB104 18483 SSS 31925 b
1 (h) (Blank).
2 (i) Following termination of an individual's
3 coverage under this paragraph 15, the individual must
4 be determined eligible before the person can be
5 re-enrolled.
6 16. Subject to appropriation, uninsured persons who
7 are not otherwise eligible under this Section who have
8 been certified and referred by the Department of Public
9 Health as having been screened and found to need
10 diagnostic evaluation or treatment, or both diagnostic
11 evaluation and treatment, for prostate or testicular
12 cancer. For the purposes of this paragraph 16, uninsured
13 persons are those who do not have creditable coverage, as
14 defined under the Health Insurance Portability and
15 Accountability Act, or have otherwise exhausted any
16 insurance benefits they may have had, for prostate or
17 testicular cancer diagnostic evaluation or treatment, or
18 both diagnostic evaluation and treatment. To be eligible,
19 a person must furnish a Social Security number. A person's
20 assets are exempt from consideration in determining
21 eligibility under this paragraph 16. Such persons shall be
22 eligible for medical assistance under this paragraph 16
23 for so long as they need treatment for the cancer. A person
24 shall be considered to need treatment if, in the opinion
25 of the person's treating physician, the person requires
26 therapy directed toward cure or palliation of prostate or
SB3365 Enrolled - 334 - LRB104 18483 SSS 31925 b
1 testicular cancer, including recurrent metastatic cancer
2 that is a known or presumed complication of prostate or
3 testicular cancer and complications resulting from the
4 treatment modalities themselves. Persons who require only
5 routine monitoring services are not considered to need
6 treatment. "Medical assistance" under this paragraph 16
7 shall be identical to the benefits provided under the
8 State's approved plan under Title XIX of the Social
9 Security Act. Notwithstanding any other provision of law,
10 the Department (i) does not have a claim against the
11 estate of a deceased recipient of services under this
12 paragraph 16 and (ii) does not have a lien against any
13 homestead property or other legal or equitable real
14 property interest owned by a recipient of services under
15 this paragraph 16.
16 17. Persons who, pursuant to a waiver approved by the
17 Secretary of the U.S. Department of Health and Human
18 Services, are eligible for medical assistance under Title
19 XIX or XXI of the federal Social Security Act.
20 Notwithstanding any other provision of this Code and
21 consistent with the terms of the approved waiver, the
22 Illinois Department, may by rule:
23 (a) Limit the geographic areas in which the waiver
24 program operates.
25 (b) Determine the scope, quantity, duration, and
26 quality, and the rate and method of reimbursement, of
SB3365 Enrolled - 335 - LRB104 18483 SSS 31925 b
1 the medical services to be provided, which may differ
2 from those for other classes of persons eligible for
3 assistance under this Article.
4 (c) Restrict the persons' freedom in choice of
5 providers.
6 18. Beginning January 1, 2014, persons aged 19 or
7 older, but younger than 65, who are not otherwise eligible
8 for medical assistance under this Section 5-2, who qualify
9 for medical assistance pursuant to 42 U.S.C.
10 1396a(a)(10)(A)(i)(VIII) to the extent permitted under
11 federal law and applicable federal regulations, and who
12 have income at or below 133% of the federal poverty level
13 plus 5% for the applicable family size as determined
14 pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal
15 regulations. Persons eligible for medical assistance under
16 this paragraph 18 shall receive coverage for the Health
17 Benefits Service Package as that term is defined in
18 subsection (m) of Section 5-1.1 of this Code. If Illinois'
19 federal medical assistance percentage (FMAP) is reduced
20 below 90% for persons eligible for medical assistance
21 under this paragraph 18, eligibility under this paragraph
22 18 shall cease no later than the end of the third month
23 following the month in which the reduction in FMAP takes
24 effect.
25 19. Beginning January 1, 2014, as required under 42
26 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
SB3365 Enrolled - 336 - LRB104 18483 SSS 31925 b
1 and younger than age 26 who are not otherwise eligible for
2 medical assistance under paragraphs (1) through (17) of
3 this Section who (i) were in foster care under the
4 responsibility of the State on the date of attaining age
5 18 or on the date of attaining age 21 when a court has
6 continued wardship for good cause as provided in Section
7 2-31 of the Juvenile Court Act of 1987 and (ii) received
8 medical assistance under the Illinois Title XIX State Plan
9 or waiver of such plan while in foster care.
10 20. (Blank).
11 21. Persons who are not otherwise eligible for medical
12 assistance under this Section who may qualify for medical
13 assistance pursuant to 42 U.S.C.
14 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
15 duration of any federal or State declared emergency due to
16 COVID-19. Medical assistance to persons eligible for
17 medical assistance solely pursuant to this paragraph 21
18 shall be limited to any in vitro diagnostic product (and
19 the administration of such product) described in 42 U.S.C.
20 1396d(a)(3)(B) on or after March 18, 2020, any visit
21 described in 42 U.S.C. 1396o(a)(2)(G), or any other
22 medical assistance that may be federally authorized for
23 this class of persons. The Department may also cover
24 treatment of COVID-19 for this class of persons, or any
25 similar category of uninsured individuals, to the extent
26 authorized under a federally approved 1115 Waiver or other
SB3365 Enrolled - 337 - LRB104 18483 SSS 31925 b
1 federal authority. Notwithstanding the provisions of
2 Section 1-11 of this Code, due to the nature of the
3 COVID-19 public health emergency, the Department may cover
4 and provide the medical assistance described in this
5 paragraph 21 to noncitizens who would otherwise meet the
6 eligibility requirements for the class of persons
7 described in this paragraph 21 for the duration of the
8 State emergency period.
9 In implementing the provisions of Public Act 96-20, the
10 Department is authorized to adopt only those rules necessary,
11 including emergency rules. Nothing in Public Act 96-20 permits
12 the Department to adopt rules or issue a decision that expands
13 eligibility for the FamilyCare Program to a person whose
14 income exceeds 185% of the Federal Poverty Level as determined
15 from time to time by the U.S. Department of Health and Human
16 Services, unless the Department is provided with express
17 statutory authority.
18 The eligibility of any such person for medical assistance
19 under this Article is not affected by the payment of any grant
20 under the Senior Citizens and Persons with Disabilities
21 Property Tax Relief Act or any distributions or items of
22 income described under subparagraph (X) of paragraph (2) of
23 subsection (a) of Section 203 of the Illinois Income Tax Act.
24 The Department shall by rule establish the amounts of
25 assets to be disregarded in determining eligibility for
26 medical assistance, which shall at a minimum equal the amounts
SB3365 Enrolled - 338 - LRB104 18483 SSS 31925 b
1 to be disregarded under the Federal Supplemental Security
2 Income Program. The amount of assets of a single person to be
3 disregarded shall not be less than $2,000, and the amount of
4 assets of a married couple to be disregarded shall not be less
5 than $3,000.
6 To the extent permitted under federal law, any person
7 found guilty of a second violation of Article VIIIA shall be
8 ineligible for medical assistance under this Article, as
9 provided in Section 8A-8.
10 The eligibility of any person for medical assistance under
11 this Article shall not be affected by the receipt by the person
12 of donations or benefits from fundraisers held for the person
13 in cases of serious illness, as long as neither the person nor
14 members of the person's family have actual control over the
15 donations or benefits or the disbursement of the donations or
16 benefits.
17 Notwithstanding any other provision of this Code, if the
18 United States Supreme Court holds Title II, Subtitle A,
19 Section 2001(a) of Public Law 111-148 to be unconstitutional,
20 or if a holding of Public Law 111-148 makes Medicaid
21 eligibility allowed under Section 2001(a) inoperable, the
22 State or a unit of local government shall be prohibited from
23 enrolling individuals in the Medical Assistance Program as the
24 result of federal approval of a State Medicaid waiver on or
25 after June 14, 2012 (the effective date of Public Act 97-687),
26 and any individuals enrolled in the Medical Assistance Program
SB3365 Enrolled - 339 - LRB104 18483 SSS 31925 b
1 pursuant to eligibility permitted as a result of such a State
2 Medicaid waiver shall become immediately ineligible.
3 Notwithstanding any other provision of this Code, if an
4 Act of Congress that becomes a Public Law eliminates Section
5 2001(a) of Public Law 111-148, the State or a unit of local
6 government shall be prohibited from enrolling individuals in
7 the Medical Assistance Program as the result of federal
8 approval of a State Medicaid waiver on or after June 14, 2012
9 (the effective date of Public Act 97-687), and any individuals
10 enrolled in the Medical Assistance Program pursuant to
11 eligibility permitted as a result of such a State Medicaid
12 waiver shall become immediately ineligible.
13 Effective October 1, 2013, the determination of
14 eligibility of persons who qualify under paragraphs 5, 6, 8,
15 15, 17, and 18 of this Section shall comply with the
16 requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
17 regulations.
18 The Department of Healthcare and Family Services, the
19 Department of Human Services, and the Illinois health
20 insurance marketplace shall work cooperatively to assist
21 persons who would otherwise lose health benefits as a result
22 of changes made under Public Act 98-104 to transition to other
23 health insurance coverage.
24 (Source: P.A. 104-9, eff. 1-1-26.)
25 (305 ILCS 5/5-2.1d)
SB3365 Enrolled - 340 - LRB104 18483 SSS 31925 b
1 Sec. 5-2.1d. Retroactive eligibility. Subject to federal
2 approval and in accordance with applicable federal law and
3 requirements, an An applicant for medical assistance may be
4 eligible for up to 3 months prior to the date of application if
5 the person would have been eligible for medical assistance at
6 the time he or she received the services if he or she had
7 applied, regardless of whether the individual is alive when
8 the application for medical assistance is made. In determining
9 financial eligibility for medical assistance for retroactive
10 months, the Department shall consider the amount of income and
11 resources and exemptions available to a person as of the first
12 day of each of the backdated months for which eligibility is
13 sought. The Department shall, by rule, establish the duration
14 of retroactive eligibility, which shall at a minimum equal the
15 duration of eligibility for federal matching funds.
16 (Source: P.A. 97-689, eff. 6-14-12.)
17 (305 ILCS 5/11-4) (from Ch. 23, par. 11-4)
18 Sec. 11-4. Applications; assistance in making
19 applications. An initial application for public assistance
20 shall be deemed an application for all such benefits to which
21 any person may be entitled except to the extent that the
22 applicant expressly declines in writing to apply for
23 particular benefits. A redetermination of eligibility shall
24 occur at least annually or for any other periodic time period
25 established by the Department by rule that is necessary to
SB3365 Enrolled - 341 - LRB104 18483 SSS 31925 b
1 implement the federal Medicaid provisions contained in Public
2 Law 119-21 and any corresponding federal regulations or
3 requirements issued by the federal Centers for Medicare and
4 Medicaid Services. A redetermination The redetermination is an
5 annual redetermination of eligibility is for of current
6 benefits and is not an initial application. The Illinois
7 Department shall provide information in writing about all
8 benefits provided under this Code to any person seeking public
9 assistance. The Illinois Department shall also provide
10 information in writing and orally to all applicants about an
11 election to have financial aid deposited directly in a
12 recipient's savings account or checking account or in any
13 electronic benefits account or accounts as provided in Section
14 11-3.1, to the extent that those elections are actually
15 available, including information on any programs administered
16 by the State Treasurer to facilitate or encourage the
17 distribution of financial aid by direct deposit or electronic
18 benefits transfer. The Illinois Department shall determine the
19 applicant's eligibility for cash assistance, medical
20 assistance and food stamps unless the applicant expressly
21 declines in writing to apply for particular benefits. The
22 Illinois Department shall adopt policies and procedures to
23 facilitate timely changes between programs that result from
24 changes in categorical eligibility factors.
25 The County departments, local governmental units and the
26 Illinois Department shall assist applicants for public
SB3365 Enrolled - 342 - LRB104 18483 SSS 31925 b
1 assistance to properly complete their applications. Such
2 assistance shall include, but not be limited to, assistance in
3 securing evidence in support of their eligibility.
4 (Source: P.A. 104-9, eff. 6-16-25.)
5 (305 ILCS 5/11-5.1)
6 Sec. 11-5.1. Eligibility verification. Notwithstanding any
7 other provision of this Code, with respect to applications for
8 medical assistance provided under Article V of this Code,
9 eligibility shall be determined in a manner that ensures
10 program integrity and complies with federal laws and
11 regulations while minimizing unnecessary barriers to
12 enrollment. To this end, as soon as practicable, and unless
13 the Department receives written denial from the federal
14 government, this Section shall be implemented:
15 (a) The Department of Healthcare and Family Services or
16 its designees shall:
17 (1) By no later than July 1, 2011, require
18 verification of, at a minimum, one month's income from all
19 sources required for determining the eligibility of
20 applicants for medical assistance under this Code. Such
21 verification shall take the form of pay stubs, business or
22 income and expense records for self-employed persons,
23 letters from employers, and any other valid documentation
24 of income including data obtained electronically by the
25 Department or its designees from other sources as
SB3365 Enrolled - 343 - LRB104 18483 SSS 31925 b
1 described in subsection (b) of this Section. A month's
2 income may be verified by a single pay stub with the
3 monthly income extrapolated from the time period covered
4 by the pay stub.
5 (2) By no later than October 1, 2011, require
6 verification of, at a minimum, one month's income from all
7 sources required for determining the continued eligibility
8 of recipients at their annual review of eligibility for
9 medical assistance under this Code. Information the
10 Department receives prior to the annual review, including
11 information available to the Department as a result of the
12 recipient's application for other non-Medicaid benefits,
13 that is sufficient to make a determination of continued
14 Medicaid eligibility may be reviewed and verified, and
15 subsequent action taken including client notification of
16 continued Medicaid eligibility. The date of client
17 notification establishes the date for subsequent annual
18 Medicaid eligibility reviews. Such verification shall take
19 the form of pay stubs, business or income and expense
20 records for self-employed persons, letters from employers,
21 and any other valid documentation of income including data
22 obtained electronically by the Department or its designees
23 from other sources as described in subsection (b) of this
24 Section. A month's income may be verified by a single pay
25 stub with the monthly income extrapolated from the time
26 period covered by the pay stub. The Department shall send
SB3365 Enrolled - 344 - LRB104 18483 SSS 31925 b
1 a notice to recipients at least 60 days prior to the end of
2 their period of eligibility that informs them of the
3 requirements for continued eligibility. If a recipient
4 does not fulfill the requirements for continued
5 eligibility by the deadline established in the notice a
6 notice of cancellation shall be issued to the recipient
7 and coverage shall end no later than the last day of the
8 month following the last day of the eligibility period. A
9 recipient's eligibility may be reinstated without
10 requiring a new application if the recipient fulfills the
11 requirements for continued eligibility prior to the end of
12 the third month following the last date of coverage (or
13 longer period if required by federal regulations). Nothing
14 in this Section shall prevent an individual whose coverage
15 has been cancelled from reapplying for health benefits at
16 any time.
17 (3) By no later than July 1, 2011, require
18 verification of Illinois residency.
19 The Department, with federal approval, may choose to adopt
20 continuous financial eligibility for a full 12 months for
21 adults on Medicaid.
22 (b) The Department shall establish or continue cooperative
23 arrangements with the Social Security Administration, the
24 Illinois Secretary of State, the Department of Human Services,
25 the Department of Revenue, the Department of Employment
26 Security, and any other appropriate entity to gain electronic
SB3365 Enrolled - 345 - LRB104 18483 SSS 31925 b
1 access, to the extent allowed by law, to information available
2 to those entities that may be appropriate for electronically
3 verifying any factor of eligibility for benefits under the
4 Program. Data relevant to eligibility shall be provided for no
5 other purpose than to verify the eligibility of new applicants
6 or current recipients of health benefits under the Program.
7 Data shall be requested or provided for any new applicant or
8 current recipient only insofar as that individual's
9 circumstances are relevant to that individual's or another
10 individual's eligibility.
11 (c) Within 90 days of the effective date of this
12 amendatory Act of the 96th General Assembly, the Department of
13 Healthcare and Family Services shall send notice to current
14 recipients informing them of the changes regarding their
15 eligibility verification.
16 (d) As soon as practical if the data is reasonably
17 available, but no later than January 1, 2017, the Department
18 shall compile on a monthly basis data on eligibility
19 redeterminations of beneficiaries of medical assistance
20 provided under Article V of this Code. In addition to the other
21 data required under this subsection, the Department shall
22 compile on a monthly basis data on the percentage of
23 beneficiaries whose eligibility is renewed through ex parte
24 redeterminations as described in subsection (b) of Section
25 5-1.6 of this Code, subject to federal approval of the changes
26 made in subsection (b) of Section 5-1.6 by this amendatory Act
SB3365 Enrolled - 346 - LRB104 18483 SSS 31925 b
1 of the 102nd General Assembly. This data shall be posted on the
2 Department's website, and data from prior months shall be
3 retained and available on the Department's website. The data
4 compiled and reported shall include the following:
5 (1) The total number of redetermination decisions made
6 in a month and, of that total number, the number of
7 decisions to continue or change benefits and the number of
8 decisions to cancel benefits.
9 (2) A breakdown of enrollee language preference for
10 the total number of redetermination decisions made in a
11 month and, of that total number, a breakdown of enrollee
12 language preference for the number of decisions to
13 continue or change benefits, and a breakdown of enrollee
14 language preference for the number of decisions to cancel
15 benefits. The language breakdown shall include, at a
16 minimum, English, Spanish, and the next 4 most commonly
17 used languages.
18 (3) The percentage of cancellation decisions made in a
19 month due to each of the following:
20 (A) The beneficiary's ineligibility due to excess
21 income.
22 (B) The beneficiary's ineligibility due to not
23 being an Illinois resident.
24 (C) The beneficiary's ineligibility due to being
25 deceased.
26 (D) The beneficiary's request to cancel benefits.
SB3365 Enrolled - 347 - LRB104 18483 SSS 31925 b
1 (E) The beneficiary's lack of response after
2 notices mailed to the beneficiary are returned to the
3 Department as undeliverable by the United States
4 Postal Service.
5 (F) The beneficiary's lack of response to a
6 request for additional information when reliable
7 information in the beneficiary's account, or other
8 more current information, is unavailable to the
9 Department to make a decision on whether to continue
10 benefits.
11 (G) Other reasons tracked by the Department for
12 the purpose of ensuring program integrity.
13 (4) If a vendor is utilized to provide services in
14 support of the Department's redetermination decision
15 process, the total number of redetermination decisions
16 made in a month and, of that total number, the number of
17 decisions to continue or change benefits, and the number
18 of decisions to cancel benefits (i) with the involvement
19 of the vendor and (ii) without the involvement of the
20 vendor.
21 (5) Of the total number of benefit cancellations in a
22 month, the number of beneficiaries who return from
23 cancellation within one month, the number of beneficiaries
24 who return from cancellation within 2 months, and the
25 number of beneficiaries who return from cancellation
26 within 3 months. Of the number of beneficiaries who return
SB3365 Enrolled - 348 - LRB104 18483 SSS 31925 b
1 from cancellation within 3 months, the percentage of those
2 cancellations due to each of the reasons listed under
3 paragraph (3) of this subsection.
4 (e) The Department shall conduct a complete review of the
5 Medicaid redetermination process in order to identify changes
6 that can increase the use of ex parte redetermination
7 processing. This review shall be completed within 90 days
8 after the effective date of this amendatory Act of the 101st
9 General Assembly. Within 90 days of completion of the review,
10 the Department shall seek written federal approval of policy
11 changes the review recommended and implement once approved.
12 The review shall specifically include, but not be limited to,
13 use of ex parte redeterminations of the following populations:
14 (1) Recipients of developmental disabilities services.
15 (2) Recipients of benefits under the State's Aid to
16 the Aged, Blind, or Disabled program.
17 (3) Recipients of Medicaid long-term care services and
18 supports, including waiver services.
19 (4) All Modified Adjusted Gross Income (MAGI)
20 populations.
21 (5) Populations with no verifiable income.
22 (6) Self-employed people.
23 The report shall also outline populations and
24 circumstances in which an ex parte redetermination is not a
25 recommended option.
26 (f) The Department shall explore and implement, as
SB3365 Enrolled - 349 - LRB104 18483 SSS 31925 b
1 practical and technologically possible, roles that
2 stakeholders outside State agencies can play to assist in
3 expediting eligibility determinations and redeterminations
4 within 24 months after the effective date of this amendatory
5 Act of the 101st General Assembly. Such practical roles to be
6 explored to expedite the eligibility determination processes
7 shall include the implementation of hospital presumptive
8 eligibility, as authorized by the Patient Protection and
9 Affordable Care Act.
10 (g) The Department or its designee shall seek federal
11 approval to enhance the reasonable compatibility standard from
12 5% to 10%.
13 (h) Reporting. The Department of Healthcare and Family
14 Services and the Department of Human Services shall publish
15 quarterly reports on their progress in implementing policies
16 and practices pursuant to this Section as modified by this
17 amendatory Act of the 101st General Assembly.
18 (1) The reports shall include, but not be limited to,
19 the following:
20 (A) Medical application processing, including a
21 breakdown of the number of MAGI, non-MAGI, long-term
22 care, and other medical cases pending for various
23 incremental time frames between 0 to 181 or more days.
24 (B) Medical redeterminations completed, including:
25 (i) a breakdown of the number of households that were
26 redetermined ex parte and those that were not; (ii)
SB3365 Enrolled - 350 - LRB104 18483 SSS 31925 b
1 the reasons households were not redetermined ex parte;
2 and (iii) the relative percentages of these reasons.
3 (C) A narrative discussion on issues identified in
4 the functioning of the State's Integrated Eligibility
5 System and progress on addressing those issues, as
6 well as progress on implementing strategies to address
7 eligibility backlogs, including expanding ex parte
8 determinations to ensure timely eligibility
9 determinations and renewals.
10 (2) Initial reports shall be issued within 90 days
11 after the effective date of this amendatory Act of the
12 101st General Assembly.
13 (3) All reports shall be published on the Department's
14 website.
15 (i) It is the determination of the General Assembly that
16 the Department must include seniors and persons with
17 disabilities in ex parte renewals. It is the determination of
18 the General Assembly that the Department must use its asset
19 verification system to assist in the determination of whether
20 an individual's coverage can be renewed using the ex parte
21 process. If a State Plan amendment is required, the Department
22 shall pursue such State Plan amendment by July 1, 2022. Within
23 60 days after receiving federal approval or guidance, the
24 Department of Healthcare and Family Services and the
25 Department of Human Services shall make necessary technical
26 and rule changes to implement these changes to the
SB3365 Enrolled - 351 - LRB104 18483 SSS 31925 b
1 redetermination process.
2 (Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20;
3 102-1037, eff. 6-2-22.)
4 (305 ILCS 5/11-5.4)
5 Sec. 11-5.4. Expedited long-term care eligibility
6 determination and enrollment.
7 (a) Establishment of the expedited long-term care
8 eligibility determination and enrollment system shall be a
9 joint venture of the Departments of Human Services and
10 Healthcare and Family Services and the Department on Aging.
11 (b) Streamlined application enrollment process; expedited
12 eligibility process. The streamlined application and
13 enrollment process must include, but need not be limited to,
14 the following:
15 (1) On or before July 1, 2019, a streamlined
16 application and enrollment process shall be put in place
17 which must include, but need not be limited to, the
18 following:
19 (A) Minimize the burden on applicants by
20 collecting only the data necessary to determine
21 eligibility for medical services, long-term care
22 services, and spousal impoverishment offset.
23 (B) Integrate online data sources to simplify the
24 application process by reducing the amount of
25 information needed to be entered and to expedite
SB3365 Enrolled - 352 - LRB104 18483 SSS 31925 b
1 eligibility verification.
2 (C) Provide online prompts to alert the applicant
3 that information is missing or not complete.
4 (D) Provide training and step-by-step written
5 instructions for caseworkers, applicants, and
6 providers.
7 (2) The State must expedite the eligibility process
8 for applicants meeting specified guidelines, regardless of
9 the age of the application. The guidelines, subject to
10 federal approval, must include, but need not be limited
11 to, the following individually or collectively:
12 (A) Full Medicaid benefits in the community for a
13 specified period of time.
14 (B) No transfer of assets or resources during the
15 federally prescribed look-back period, as specified in
16 federal law.
17 (C) Receives Supplemental Security Income payments
18 or was receiving such payments at the time of
19 admission to a nursing facility.
20 (D) For applicants or recipients with verified
21 income at or below 100% of the federal poverty level
22 when the declared value of their countable resources
23 is no greater than the allowable amounts pursuant to
24 Section 5-2 of this Code for classes of eligible
25 persons for whom a resource limit applies. Such
26 simplified verification policies shall apply to
SB3365 Enrolled - 353 - LRB104 18483 SSS 31925 b
1 community cases as well as long-term care cases.
2 (3) Subject to federal approval, the Department of
3 Healthcare and Family Services must implement an ex parte
4 renewal process for Medicaid-eligible individuals residing
5 in long-term care facilities. "Renewal" has the same
6 meaning as "redetermination" in State policies,
7 administrative rule, and federal Medicaid law. The ex
8 parte renewal process must be fully operational on or
9 before January 1, 2019. If an individual has transferred
10 to another long-term care facility, any annual notice
11 concerning redetermination of eligibility must be sent to
12 the long-term care facility where the individual resides
13 as well as to the individual.
14 (4) The Department of Human Services must use the
15 standards and distribution requirements described in this
16 subsection and in Section 11-6 for notification of missing
17 supporting documents and information during all phases of
18 the application process: initial, renewal, and appeal.
19 (c) The Department of Human Services must adopt policies
20 and procedures to improve communication between long-term care
21 benefits central office personnel, applicants and their
22 representatives, and facilities in which the applicants
23 reside. Such policies and procedures must at a minimum permit
24 applicants and their representatives and the facility in which
25 the applicants reside to speak directly to an individual
26 trained to take telephone inquiries and provide appropriate
SB3365 Enrolled - 354 - LRB104 18483 SSS 31925 b
1 responses.
2 (d) Effective 30 days after the completion of 3 regionally
3 based trainings, nursing facilities shall submit all
4 applications for medical assistance online via the Application
5 for Benefits Eligibility (ABE) website. This requirement shall
6 extend to scanning and uploading with the online application
7 any required additional forms such as the Long Term Care
8 Facility Notification and the Additional Financial Information
9 for Long Term Care Applicants as well as scanned copies of any
10 supporting documentation. Long-term care facility admission
11 documents must be submitted as required in Section 5-5 of this
12 Code. No local Department of Human Services office shall
13 refuse to accept an electronically filed application. No
14 Department of Human Services office shall request submission
15 of any document in hard copy.
16 (e) Notwithstanding any other provision of this Code, the
17 Department of Human Services and the Department of Healthcare
18 and Family Services' Office of the Inspector General shall,
19 upon request, allow an applicant additional time to submit
20 information and documents needed as part of a review of
21 available resources or resources transferred during the
22 look-back period. The initial extension shall not exceed 30
23 days. A second extension of 30 days may be granted upon
24 request. Any request for information issued by the State to an
25 applicant shall include the following: an explanation of the
26 information required and the date by which the information
SB3365 Enrolled - 355 - LRB104 18483 SSS 31925 b
1 must be submitted; a statement that failure to respond in a
2 timely manner can result in denial of the application; a
3 statement that the applicant or the facility in the name of the
4 applicant may seek an extension; and the name and contact
5 information of a caseworker in case of questions. Any such
6 request for information shall also be sent to the facility. In
7 deciding whether to grant an extension, the Department of
8 Human Services or the Department of Healthcare and Family
9 Services' Office of the Inspector General shall take into
10 account what is in the best interest of the applicant. The time
11 limits for processing an application shall be tolled during
12 the period of any extension granted under this subsection.
13 (f) The Department of Human Services and the Department of
14 Healthcare and Family Services must jointly compile data on
15 pending applications, denials, appeals, and redeterminations
16 into a monthly report, which shall be posted on each
17 Department's website for the purposes of monitoring long-term
18 care eligibility processing. The report must specify the
19 number of applications and redeterminations pending long-term
20 care eligibility determination and admission and the number of
21 appeals of denials in the following categories:
22 (A) Length of time applications, redeterminations, and
23 appeals are pending - 0 to 45 days, 46 days to 90 days, 91
24 days to 180 days, 181 days to 12 months, over 12 months to
25 18 months, over 18 months to 24 months, and over 24 months.
26 (B) Percentage of applications and redeterminations
SB3365 Enrolled - 356 - LRB104 18483 SSS 31925 b
1 pending in the Department of Human Services' Family
2 Community Resource Centers, in the Department of Human
3 Services' long-term care hubs, with the Department of
4 Healthcare and Family Services' Office of Inspector
5 General, and those applications which are being tolled due
6 to requests for extension of time for additional
7 information.
8 (C) Status of pending applications, denials, appeals,
9 and redeterminations.
10 (g) Beginning on July 1, 2017, the Auditor General shall
11 report every 3 years to the General Assembly on the
12 performance and compliance of the Department of Healthcare and
13 Family Services, the Department of Human Services, and the
14 Department on Aging in meeting the requirements of this
15 Section and the federal requirements concerning eligibility
16 determinations for Medicaid long-term care services and
17 supports, and shall report any issues or deficiencies and make
18 recommendations. The Auditor General shall, at a minimum,
19 review, consider, and evaluate the following:
20 (1) compliance with federal regulations on furnishing
21 services as related to Medicaid long-term care services
22 and supports as provided under 42 CFR 435.930;
23 (2) compliance with federal regulations on the timely
24 determination of eligibility as provided under 42 CFR
25 435.912;
26 (3) the accuracy and completeness of the report
SB3365 Enrolled - 357 - LRB104 18483 SSS 31925 b
1 required under paragraph (9) of subsection (e);
2 (4) the efficacy and efficiency of the task-based
3 process used for making eligibility determinations in the
4 centralized offices of the Department of Human Services
5 for long-term care services, including the role of the
6 State's integrated eligibility system, as opposed to the
7 traditional caseworker-specific process from which these
8 central offices have converted; and
9 (5) any issues affecting eligibility determinations
10 related to the Department of Human Services' staff
11 completing Medicaid eligibility determinations instead of
12 the designated single-state Medicaid agency in Illinois,
13 the Department of Healthcare and Family Services.
14 The Auditor General's report shall include any and all
15 other areas or issues which are identified through an annual
16 review. Paragraphs (1) through (5) of this subsection shall
17 not be construed to limit the scope of the annual review and
18 the Auditor General's authority to thoroughly and completely
19 evaluate any and all processes, policies, and procedures
20 concerning compliance with federal and State law requirements
21 on eligibility determinations for Medicaid long-term care
22 services and supports.
23 (h) The Department of Healthcare and Family Services shall
24 adopt any rules necessary to administer and enforce any
25 provision of this Section. Rulemaking shall not delay the full
26 implementation of this Section.
SB3365 Enrolled - 358 - LRB104 18483 SSS 31925 b
1 (i) Beginning on June 29, 2018, provisional eligibility
2 for medical assistance under Article V of this Code, in the
3 form of a recipient identification number and any other
4 necessary credentials to permit an applicant to receive
5 covered services under Article V, must be issued to any
6 applicant who has not received a determination on his or her
7 application for Medicaid and Medicaid long-term care services
8 filed simultaneously or, if already Medicaid enrolled,
9 application for Medicaid long-term care services under Article
10 V of this Code within the federally prescribed timeliness
11 requirements for determinations on such applications. The
12 Department of Healthcare and Family Services must maintain the
13 applicant's provisional eligibility status until a
14 determination is made on the individual's application for
15 long-term care services. The Department of Healthcare and
16 Family Services or the managed care organization, if
17 applicable, must reimburse providers for services rendered
18 during an applicant's provisional eligibility period.
19 (1) Claims for services rendered to an applicant with
20 provisional eligibility status must be submitted and
21 processed in the same manner as those submitted on behalf
22 of beneficiaries determined to qualify for benefits.
23 (2) An applicant with provisional eligibility status
24 must have his or her long-term care benefits paid for
25 under the State's fee-for-service system during the period
26 of provisional eligibility. If an individual otherwise
SB3365 Enrolled - 359 - LRB104 18483 SSS 31925 b
1 eligible for medical assistance under Article V of this
2 Code is enrolled with a managed care organization for
3 community benefits at the time the individual's
4 provisional eligibility for long-term care services is
5 issued, the managed care organization is only responsible
6 for paying benefits covered under the capitation payment
7 received by the managed care organization for the
8 individual.
9 (3) The Department of Healthcare and Family Services,
10 within 10 business days of issuing provisional eligibility
11 to an applicant, must submit to the Office of the
12 Comptroller for payment a voucher for all retroactive
13 reimbursement due. The Department of Healthcare and Family
14 Services must clearly identify such vouchers as
15 provisional eligibility vouchers.
16 (Source: P.A. 101-101, eff. 1-1-20; 101-209, eff. 8-5-19;
17 101-265, eff. 8-9-19; 101-559, eff. 8-23-19; 102-558, eff.
18 8-20-21.)
19 ARTICLE 225.
20 Section 225-5. The Illinois Act on the Aging is amended by
21 changing Section 4.02 as follows:
22 (20 ILCS 105/4.02)
23 Sec. 4.02. Community Care Program. The Department shall
SB3365 Enrolled - 360 - LRB104 18483 SSS 31925 b
1 establish a program of services to prevent unnecessary
2 institutionalization of persons age 60 and older in need of
3 long term care or who are established as persons who suffer
4 from Alzheimer's disease or a related disorder under the
5 Alzheimer's Disease Assistance Act, thereby enabling them to
6 remain in their own homes or in other living arrangements.
7 Such preventive services, which may be coordinated with other
8 programs for the aged, may include, but are not limited to, any
9 or all of the following:
10 (a) (blank);
11 (b) (blank);
12 (c) home care aide services;
13 (d) personal assistant services;
14 (e) adult day services;
15 (f) home-delivered meals;
16 (g) education in self-care;
17 (h) personal care services;
18 (i) adult day health services;
19 (j) habilitation services;
20 (k) respite care;
21 (k-5) community reintegration services;
22 (k-6) flexible senior services;
23 (k-7) medication management;
24 (k-8) emergency home response;
25 (l) other nonmedical social services that may enable
26 the person to become self-supporting; or
SB3365 Enrolled - 361 - LRB104 18483 SSS 31925 b
1 (m) (blank).
2 The Department shall establish eligibility standards for
3 such services. In determining the amount and nature of
4 services for which a person may qualify, consideration shall
5 not be given to the value of cash, property, or other assets
6 held in the name of the person's spouse pursuant to a written
7 agreement dividing marital property into equal but separate
8 shares or pursuant to a transfer of the person's interest in a
9 home to his spouse, provided that the spouse's share of the
10 marital property is not made available to the person seeking
11 such services.
12 The Department shall require as a condition of eligibility
13 that all new financially eligible applicants apply for and
14 enroll in medical assistance under Article V of the Illinois
15 Public Aid Code in accordance with rules promulgated by the
16 Department.
17 The Department shall, in conjunction with the Department
18 of Public Aid (now Department of Healthcare and Family
19 Services), seek appropriate amendments under Sections 1915 and
20 1924 of the Social Security Act. The purpose of the amendments
21 shall be to extend eligibility for home and community based
22 services under Sections 1915 and 1924 of the Social Security
23 Act to persons who transfer to or for the benefit of a spouse
24 those amounts of income and resources allowed under Section
25 1924 of the Social Security Act. Subject to the approval of
26 such amendments, the Department shall extend the provisions of
SB3365 Enrolled - 362 - LRB104 18483 SSS 31925 b
1 Section 5-4 of the Illinois Public Aid Code to persons who, but
2 for the provision of home or community-based services, would
3 require the level of care provided in an institution, as is
4 provided for in federal law. Those persons no longer found to
5 be eligible for receiving noninstitutional services due to
6 changes in the eligibility criteria shall be given 45 days
7 notice prior to actual termination. Those persons receiving
8 notice of termination may contact the Department and request
9 the determination be appealed at any time during the 45 day
10 notice period. The target population identified for the
11 purposes of this Section are persons age 60 and older with an
12 identified service need. Priority shall be given to those who
13 are at imminent risk of institutionalization. The services
14 shall be provided to eligible persons age 60 and older to the
15 extent that the cost of the services together with the other
16 personal maintenance expenses of the persons are reasonably
17 related to the standards established for care in a group
18 facility appropriate to the person's condition. These
19 noninstitutional services, pilot projects, or experimental
20 facilities may be provided as part of or in addition to those
21 authorized by federal law or those funded and administered by
22 the Department of Human Services. The Departments of Human
23 Services, Healthcare and Family Services, Public Health,
24 Veterans' Affairs, and Commerce and Economic Opportunity and
25 other appropriate agencies of State, federal, and local
26 governments shall cooperate with the Department on Aging in
SB3365 Enrolled - 363 - LRB104 18483 SSS 31925 b
1 the establishment and development of the noninstitutional
2 services. The Department shall require an annual audit from
3 all personal assistant and home care aide vendors contracting
4 with the Department under this Section. The annual audit shall
5 assure that each audited vendor's procedures are in compliance
6 with Department's financial reporting guidelines requiring an
7 administrative and employee wage and benefits cost split as
8 defined in administrative rules. The audit is a public record
9 under the Freedom of Information Act. The Department shall
10 execute, relative to the nursing home prescreening project,
11 written inter-agency agreements with the Department of Human
12 Services and the Department of Healthcare and Family Services,
13 to effect the following: (1) intake procedures and common
14 eligibility criteria for those persons who are receiving
15 noninstitutional services; and (2) the establishment and
16 development of noninstitutional services in areas of the State
17 where they are not currently available or are undeveloped. On
18 and after July 1, 1996, all nursing home prescreenings for
19 individuals 60 years of age or older shall be conducted by the
20 Department.
21 As part of the Department on Aging's routine training of
22 case managers and case manager supervisors, the Department may
23 include information on family futures planning for persons who
24 are age 60 or older and who are caregivers of their adult
25 children with developmental disabilities. The content of the
26 training shall be at the Department's discretion.
SB3365 Enrolled - 364 - LRB104 18483 SSS 31925 b
1 The Department is authorized to establish a system of
2 recipient copayment for services provided under this Section,
3 such copayment to be based upon the recipient's ability to pay
4 but in no case to exceed the actual cost of the services
5 provided. Additionally, any portion of a person's income which
6 is equal to or less than the federal poverty standard shall not
7 be considered by the Department in determining the copayment.
8 The level of such copayment shall be adjusted whenever
9 necessary to reflect any change in the officially designated
10 federal poverty standard.
11 The Department, or the Department's authorized
12 representative, may recover the amount of moneys expended for
13 services provided to or in behalf of a person under this
14 Section by a claim against the person's estate or against the
15 estate of the person's surviving spouse, but no recovery may
16 be had until after the death of the surviving spouse, if any,
17 and then only at such time when there is no surviving child who
18 is under age 21 or blind or who has a permanent and total
19 disability. This paragraph, however, shall not bar recovery,
20 at the death of the person, of moneys for services provided to
21 the person or in behalf of the person under this Section to
22 which the person was not entitled; provided that such recovery
23 shall not be enforced against any real estate while it is
24 occupied as a homestead by the surviving spouse or other
25 dependent, if no claims by other creditors have been filed
26 against the estate, or, if such claims have been filed, they
SB3365 Enrolled - 365 - LRB104 18483 SSS 31925 b
1 remain dormant for failure of prosecution or failure of the
2 claimant to compel administration of the estate for the
3 purpose of payment. This paragraph shall not bar recovery from
4 the estate of a spouse, under Sections 1915 and 1924 of the
5 Social Security Act and Section 5-4 of the Illinois Public Aid
6 Code, who precedes a person receiving services under this
7 Section in death. All moneys for services paid to or in behalf
8 of the person under this Section shall be claimed for recovery
9 from the deceased spouse's estate. "Homestead", as used in
10 this paragraph, means the dwelling house and contiguous real
11 estate occupied by a surviving spouse or relative, as defined
12 by the rules and regulations of the Department of Healthcare
13 and Family Services, regardless of the value of the property.
14 The Department shall increase the effectiveness of the
15 existing Community Care Program by:
16 (1) ensuring that in-home services included in the
17 care plan are available on evenings and weekends;
18 (2) ensuring that care plans contain the services that
19 eligible participants need based on the number of days in
20 a month, not limited to specific blocks of time, as
21 identified by the comprehensive assessment tool selected
22 by the Department for use statewide, not to exceed the
23 total monthly service cost maximum allowed for each
24 service; the Department shall develop administrative rules
25 to implement this item (2);
26 (3) ensuring that the participants have the right to
SB3365 Enrolled - 366 - LRB104 18483 SSS 31925 b
1 choose the services contained in their care plan and to
2 direct how those services are provided, based on
3 administrative rules established by the Department;
4 (4)(blank);
5 (5) ensuring that homemakers can provide personal care
6 services that may or may not involve contact with clients,
7 including, but not limited to:
8 (A) bathing;
9 (B) grooming;
10 (C) toileting;
11 (D) nail care;
12 (E) transferring;
13 (F) respiratory services;
14 (G) exercise; or
15 (H) positioning;
16 (6) ensuring that homemaker program vendors are not
17 restricted from hiring homemakers who are family members
18 of clients or recommended by clients; the Department may
19 not, by rule or policy, require homemakers who are family
20 members of clients or recommended by clients to accept
21 assignments in homes other than the client;
22 (7) ensuring that the State may access maximum federal
23 matching funds by seeking approval for the Centers for
24 Medicare and Medicaid Services for modifications to the
25 State's home and community based services waiver and
26 additional waiver opportunities, including applying for
SB3365 Enrolled - 367 - LRB104 18483 SSS 31925 b
1 enrollment in the Balance Incentive Payment Program by May
2 1, 2013, in order to maximize federal matching funds; this
3 shall include, but not be limited to, modification that
4 reflects all changes in the Community Care Program
5 services and all increases in the services cost maximum;
6 (8) ensuring that the determination of need tool
7 accurately reflects the service needs of individuals with
8 Alzheimer's disease and related dementia disorders;
9 (9) ensuring that services are authorized accurately
10 and consistently for the Community Care Program (CCP); the
11 Department shall implement a Service Authorization policy
12 directive; the purpose shall be to ensure that eligibility
13 and services are authorized accurately and consistently in
14 the CCP program; the policy directive shall clarify
15 service authorization guidelines to Care Coordination
16 Units and Community Care Program providers no later than
17 May 1, 2013;
18 (10) working in conjunction with Care Coordination
19 Units, the Department of Healthcare and Family Services,
20 the Department of Human Services, Community Care Program
21 providers, and other stakeholders to make improvements to
22 the Medicaid claiming processes and the Medicaid
23 enrollment procedures or requirements as needed,
24 including, but not limited to, specific policy changes or
25 rules to improve the up-front enrollment of participants
26 in the Medicaid program and specific policy changes or
SB3365 Enrolled - 368 - LRB104 18483 SSS 31925 b
1 rules to ensure insure more prompt submission of bills to
2 the federal government to secure maximum federal matching
3 dollars as promptly as possible; the Department on Aging
4 shall have at least 3 meetings with stakeholders by
5 January 1, 2014 in order to address these improvements;
6 (11) requiring home care service providers to comply
7 with the rounding of hours worked provisions under the
8 federal Fair Labor Standards Act (FLSA) and as set forth
9 in 29 CFR 785.48(b) by May 1, 2013;
10 (12) implementing any necessary policy changes or
11 promulgating any rules, no later than January 1, 2014, to
12 assist the Department of Healthcare and Family Services in
13 moving as many participants as possible, consistent with
14 federal regulations, into coordinated care plans if a care
15 coordination plan that covers long term care is available
16 in the recipient's area; and
17 (13) (blank).
18 By January 1, 2009 or as soon after the end of the Cash and
19 Counseling Demonstration Project as is practicable, the
20 Department may, based on its evaluation of the demonstration
21 project, promulgate rules concerning personal assistant
22 services, to include, but need not be limited to,
23 qualifications, employment screening, rights under fair labor
24 standards, training, fiduciary agent, and supervision
25 requirements. All applicants shall be subject to the
26 provisions of the Health Care Worker Background Check Act.
SB3365 Enrolled - 369 - LRB104 18483 SSS 31925 b
1 The Department shall develop procedures to enhance
2 availability of services on evenings, weekends, and on an
3 emergency basis to meet the respite needs of caregivers.
4 Procedures shall be developed to permit the utilization of
5 services in successive blocks of 24 hours up to the monthly
6 maximum established by the Department. Workers providing these
7 services shall be appropriately trained.
8 No person may perform chore/housekeeping and home care
9 aide services under a program authorized by this Section
10 unless that person has been issued a certificate of
11 pre-service to do so by his or her employing agency.
12 Information gathered to effect such certification shall
13 include (i) the person's name, (ii) the date the person was
14 hired by his or her current employer, and (iii) the training,
15 including dates and levels. Persons engaged in the program
16 authorized by this Section before the effective date of this
17 amendatory Act of 1991 shall be issued a certificate of all
18 pre-service and in-service training from his or her employer
19 upon submitting the necessary information. The employing
20 agency shall be required to retain records of all staff
21 pre-service and in-service training, and shall provide such
22 records to the Department upon request and upon termination of
23 the employer's contract with the Department. In addition, the
24 employing agency is responsible for the issuance of
25 certifications of in-service training completed to their
26 employees.
SB3365 Enrolled - 370 - LRB104 18483 SSS 31925 b
1 The Department is required to develop a system to ensure
2 that persons working as home care aides and personal
3 assistants receive increases in their wages when the federal
4 minimum wage is increased by requiring vendors to certify that
5 they are meeting the federal minimum wage statute for home
6 care aides and personal assistants. An employer that cannot
7 ensure that the minimum wage increase is being given to home
8 care aides and personal assistants shall be denied any
9 increase in reimbursement costs.
10 The Community Care Program Advisory Committee is created
11 in the Department on Aging. The Director shall appoint
12 individuals to serve in the Committee, who shall serve at
13 their own expense. Members of the Committee must abide by all
14 applicable ethics laws. The Committee shall advise the
15 Department on issues related to the Department's program of
16 services to prevent unnecessary institutionalization. The
17 Committee shall meet on a bi-monthly basis and shall serve to
18 identify and advise the Department on present and potential
19 issues affecting the service delivery network, the program's
20 clients, and the Department and to recommend solution
21 strategies. Persons appointed to the Committee shall be
22 appointed on, but not limited to, their own and their agency's
23 experience with the program, geographic representation, and
24 willingness to serve. The Director shall appoint members to
25 the Committee to represent provider, advocacy, policy
26 research, and other constituencies committed to the delivery
SB3365 Enrolled - 371 - LRB104 18483 SSS 31925 b
1 of high quality home and community-based services to older
2 adults. Representatives shall be appointed to ensure
3 representation from community care providers, including, but
4 not limited to, adult day service providers, homemaker
5 providers, case coordination and case management units,
6 emergency home response providers, statewide trade or labor
7 unions that represent home care aides and direct care staff,
8 area agencies on aging, adults over age 60, membership
9 organizations representing older adults, and other
10 organizational entities, providers of care, or individuals
11 with demonstrated interest and expertise in the field of home
12 and community care as determined by the Director.
13 Nominations may be presented from any agency or State
14 association with interest in the program. The Director, or his
15 or her designee, shall serve as the permanent co-chair of the
16 advisory committee. One other co-chair shall be nominated and
17 approved by the members of the committee on an annual basis.
18 Committee members' terms of appointment shall be for 4 years
19 with one-quarter of the appointees' terms expiring each year.
20 A member shall continue to serve until his or her replacement
21 is named. The Department shall fill vacancies that have a
22 remaining term of over one year, and this replacement shall
23 occur through the annual replacement of expiring terms. The
24 Director shall designate Department staff to provide technical
25 assistance and staff support to the committee. Department
26 representation shall not constitute membership of the
SB3365 Enrolled - 372 - LRB104 18483 SSS 31925 b
1 committee. All Committee papers, issues, recommendations,
2 reports, and meeting memoranda are advisory only. The
3 Director, or his or her designee, shall make a written report,
4 as requested by the Committee, regarding issues before the
5 Committee.
6 The Department on Aging and the Department of Human
7 Services shall cooperate in the development and submission of
8 an annual report on programs and services provided under this
9 Section. Such joint report shall be filed with the Governor
10 and the General Assembly on or before March 31 of the following
11 fiscal year.
12 The requirement for reporting to the General Assembly
13 shall be satisfied by filing copies of the report as required
14 by Section 3.1 of the General Assembly Organization Act and
15 filing such additional copies with the State Government Report
16 Distribution Center for the General Assembly as is required
17 under paragraph (t) of Section 7 of the State Library Act.
18 Those persons previously found eligible for receiving
19 noninstitutional services whose services were discontinued
20 under the Emergency Budget Act of Fiscal Year 1992, and who do
21 not meet the eligibility standards in effect on or after July
22 1, 1992, shall remain ineligible on and after July 1, 1992.
23 Those persons previously not required to cost-share and who
24 were required to cost-share effective March 1, 1992, shall
25 continue to meet cost-share requirements on and after July 1,
26 1992. Beginning July 1, 1992, all clients will be required to
SB3365 Enrolled - 373 - LRB104 18483 SSS 31925 b
1 meet eligibility, cost-share, and other requirements and will
2 have services discontinued or altered when they fail to meet
3 these requirements.
4 For the purposes of this Section, "flexible senior
5 services" refers to services that require one-time or periodic
6 expenditures, including, but not limited to, respite care,
7 home modification, assistive technology, housing assistance,
8 and transportation.
9 The Department shall implement an electronic service
10 verification based on global positioning systems or other
11 cost-effective technology for the Community Care Program no
12 later than January 1, 2014.
13 The Department shall require, as a condition of
14 eligibility, application for the medical assistance program
15 under Article V of the Illinois Public Aid Code.
16 The Department may authorize Community Care Program
17 services until an applicant is determined eligible for medical
18 assistance under Article V of the Illinois Public Aid Code.
19 The Department shall continue to provide Community Care
20 Program reports as required by statute, which shall include an
21 annual report on Care Coordination Unit performance and
22 adherence to service guidelines and a 6-month supplemental
23 report.
24 In regard to community care providers, failure to comply
25 with Department on Aging policies shall be cause for
26 disciplinary action, including, but not limited to,
SB3365 Enrolled - 374 - LRB104 18483 SSS 31925 b
1 disqualification from serving Community Care Program clients.
2 Each provider, upon submission of any bill or invoice to the
3 Department for payment for services rendered, shall include a
4 notarized statement, under penalty of perjury pursuant to
5 Section 1-109 of the Code of Civil Procedure, that the
6 provider has complied with all Department policies.
7 The Director of the Department on Aging shall make
8 information available to the State Board of Elections as may
9 be required by an agreement the State Board of Elections has
10 entered into with a multi-state voter registration list
11 maintenance system.
12 The Department shall pay an enhanced rate of at least
13 $1.77 per unit under the Community Care Program to those
14 in-home service provider agencies that offer health insurance
15 coverage as a benefit to their direct service worker employees
16 pursuant to rules adopted by the Department. The Department
17 shall review the enhanced rate as part of its process to rebase
18 in-home service provider reimbursement rates pursuant to
19 federal waiver requirements. Subject to federal approval,
20 beginning on January 1, 2024, rates for adult day services
21 shall be increased to $16.84 per hour and rates for each way
22 transportation services for adult day services shall be
23 increased to $12.44 per unit transportation.
24 Subject to federal approval, on and after January 1, 2024,
25 rates for homemaker services shall be increased to $28.07 to
26 sustain a minimum wage of $17 per hour for direct service
SB3365 Enrolled - 375 - LRB104 18483 SSS 31925 b
1 workers. Rates in subsequent State fiscal years shall be no
2 lower than the rates put into effect upon federal approval.
3 Providers of in-home services shall be required to certify to
4 the Department that they remain in compliance with the
5 mandated wage increase for direct service workers. Fringe
6 benefits, including, but not limited to, paid time off and
7 payment for training, health insurance, travel, or
8 transportation, shall not be reduced in relation to the rate
9 increases described in this paragraph.
10 Subject to and upon federal approval, on and after January
11 1, 2025, rates for homemaker services shall be increased to
12 $29.63 to sustain a minimum wage of $18 per hour for direct
13 service workers. Rates in subsequent State fiscal years shall
14 be no lower than the rates put into effect upon federal
15 approval. Providers of in-home services shall be required to
16 certify to the Department that they remain in compliance with
17 the mandated wage increase for direct service workers. Fringe
18 benefits, including, but not limited to, paid time off and
19 payment for training, health insurance, travel, or
20 transportation, shall not be reduced in relation to the rate
21 increases described in this paragraph.
22 Subject to and upon federal approval, on and after January
23 1, 2026, rates for homemaker services shall be increased to
24 $30.80 to sustain a minimum wage of $18.75 per hour for direct
25 service workers. Rates in subsequent State fiscal years shall
26 be no lower than the rates put into effect upon federal
SB3365 Enrolled - 376 - LRB104 18483 SSS 31925 b
1 approval. Providers of in-home services shall be required to
2 certify to the Department that they remain in compliance with
3 the mandated wage increase for direct service workers. Fringe
4 benefits, including, but not limited to, paid time off and
5 payment for training, health insurance, travel, or
6 transportation, shall not be reduced in relation to the rate
7 increases described in this paragraph.
8 The General Assembly finds it necessary to authorize an
9 aggressive Medicaid enrollment initiative designed to maximize
10 federal Medicaid funding for the Community Care Program which
11 produces significant savings for the State of Illinois. The
12 Department on Aging shall establish and implement a Community
13 Care Program Medicaid Initiative. Under the Initiative, the
14 Department on Aging shall, at a minimum: (i) provide an
15 enhanced rate to adequately compensate care coordination units
16 to enroll eligible Community Care Program clients into
17 Medicaid; (ii) use recommendations from a stakeholder
18 committee on how best to implement the Initiative; and (iii)
19 establish requirements for State agencies to make enrollment
20 in the State's Medical Assistance program easier for seniors.
21 The Community Care Program Medicaid Enrollment Oversight
22 Subcommittee is created as a subcommittee of the Older Adult
23 Services Advisory Committee established in Section 35 of the
24 Older Adult Services Act to make recommendations on how best
25 to increase the number of medical assistance recipients who
26 are enrolled in the Community Care Program. The Subcommittee
SB3365 Enrolled - 377 - LRB104 18483 SSS 31925 b
1 shall consist of all of the following persons who must be
2 appointed within 30 days after June 4, 2018 (the effective
3 date of Public Act 100-587):
4 (1) The Director of Aging, or his or her designee, who
5 shall serve as the chairperson of the Subcommittee.
6 (2) One representative of the Department of Healthcare
7 and Family Services, appointed by the Director of
8 Healthcare and Family Services.
9 (3) One representative of the Department of Human
10 Services, appointed by the Secretary of Human Services.
11 (4) One individual representing a care coordination
12 unit, appointed by the Director of Aging.
13 (5) One individual from a non-governmental statewide
14 organization that advocates for seniors, appointed by the
15 Director of Aging.
16 (6) One individual representing Area Agencies on
17 Aging, appointed by the Director of Aging.
18 (7) One individual from a statewide association
19 dedicated to Alzheimer's care, support, and research,
20 appointed by the Director of Aging.
21 (8) One individual from an organization that employs
22 persons who provide services under the Community Care
23 Program, appointed by the Director of Aging.
24 (9) One member of a trade or labor union representing
25 persons who provide services under the Community Care
26 Program, appointed by the Director of Aging.
SB3365 Enrolled - 378 - LRB104 18483 SSS 31925 b
1 (10) One member of the Senate, who shall serve as
2 co-chairperson, appointed by the President of the Senate.
3 (11) One member of the Senate, who shall serve as
4 co-chairperson, appointed by the Minority Leader of the
5 Senate.
6 (12) One member of the House of Representatives, who
7 shall serve as co-chairperson, appointed by the Speaker of
8 the House of Representatives.
9 (13) One member of the House of Representatives, who
10 shall serve as co-chairperson, appointed by the Minority
11 Leader of the House of Representatives.
12 (14) One individual appointed by a labor organization
13 representing frontline employees at the Department of
14 Human Services.
15 The Subcommittee shall provide oversight to the Community
16 Care Program Medicaid Initiative and shall meet quarterly. At
17 each Subcommittee meeting the Department on Aging shall
18 provide the following data sets to the Subcommittee: (A) the
19 number of Illinois residents, categorized by planning and
20 service area, who are receiving services under the Community
21 Care Program and are enrolled in the State's Medical
22 Assistance Program; (B) the number of Illinois residents,
23 categorized by planning and service area, who are receiving
24 services under the Community Care Program, but are not
25 enrolled in the State's Medical Assistance Program; and (C)
26 the number of Illinois residents, categorized by planning and
SB3365 Enrolled - 379 - LRB104 18483 SSS 31925 b
1 service area, who are receiving services under the Community
2 Care Program and are eligible for benefits under the State's
3 Medical Assistance Program, but are not enrolled in the
4 State's Medical Assistance Program. In addition to this data,
5 the Department on Aging shall provide the Subcommittee with
6 plans on how the Department on Aging will reduce the number of
7 Illinois residents who are not enrolled in the State's Medical
8 Assistance Program but who are eligible for medical assistance
9 benefits. The Department on Aging shall enroll in the State's
10 Medical Assistance Program those Illinois residents who
11 receive services under the Community Care Program and are
12 eligible for medical assistance benefits but are not enrolled
13 in the State's Medicaid Assistance Program. The data provided
14 to the Subcommittee shall be made available to the public via
15 the Department on Aging's website.
16 The Department on Aging, with the involvement of the
17 Subcommittee, shall collaborate with the Department of Human
18 Services and the Department of Healthcare and Family Services
19 on how best to achieve the responsibilities of the Community
20 Care Program Medicaid Initiative.
21 The Department on Aging, the Department of Human Services,
22 and the Department of Healthcare and Family Services shall
23 coordinate and implement a streamlined process for seniors to
24 access benefits under the State's Medical Assistance Program.
25 The Subcommittee shall collaborate with the Department of
26 Human Services on the adoption of a uniform application
SB3365 Enrolled - 380 - LRB104 18483 SSS 31925 b
1 submission process. The Department of Human Services and any
2 other State agency involved with processing the medical
3 assistance application of any person enrolled in the Community
4 Care Program shall include the appropriate care coordination
5 unit in all communications related to the determination or
6 status of the application.
7 The Community Care Program Medicaid Initiative shall
8 provide targeted funding to care coordination units to help
9 seniors complete their applications for medical assistance
10 benefits. On and after July 1, 2019, care coordination units
11 shall receive no less than $200 per completed application,
12 which rate may be included in a bundled rate for initial intake
13 services when Medicaid application assistance is provided in
14 conjunction with the initial intake process for new program
15 participants.
16 The Community Care Program Medicaid Initiative shall cease
17 operation 5 years after June 4, 2018 (the effective date of
18 Public Act 100-587), after which the Subcommittee shall
19 dissolve.
20 Effective July 1, 2023 through June 30, 2026, subject to
21 federal approval, the Department on Aging shall reimburse Care
22 Coordination Units at the following rates for case management
23 services: $252.40 for each initial assessment; $366.40 for
24 each initial assessment with translation; $229.68 for each
25 redetermination assessment; $313.68 for each redetermination
26 assessment with translation; $200.00 for each completed
SB3365 Enrolled - 381 - LRB104 18483 SSS 31925 b
1 application for medical assistance benefits; $132.26 for each
2 face-to-face, choices-for-care screening; $168.26 for each
3 face-to-face, choices-for-care screening with translation;
4 $124.56 for each 6-month, face-to-face visit; $132.00 for each
5 MCO participant eligibility determination; and $157.00 for
6 each MCO participant eligibility determination with
7 translation.
8 Effective July 1, 2026, subject to federal approval, the
9 Department on Aging shall reimburse Care Coordination Units at
10 the following rates for case management services: $252.40 for
11 each initial assessment; $366.40 for each initial assessment
12 with translation; $229.68 for each redetermination assessment;
13 $313.68 for each redetermination assessment with translation;
14 $200.00 for each completed application for medical assistance
15 benefits; $132.26 for each face-to-face, choices-for-care
16 screening; $168.26 for each face-to-face, choices-for-care
17 screening with translation; $124.56 for each 6-month,
18 face-to-face visit; $172 for each managed care participant
19 eligibility determination; $197.00 for each managed care
20 participant eligibility determination with translation; and
21 $90 for each administration of a participant transfer from
22 non-managed care CCP to managed care CCP or from managed care
23 CCP to non-managed care CCP.
24 (Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
25 45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
26 1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;
SB3365 Enrolled - 382 - LRB104 18483 SSS 31925 b
1 103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
2 1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)
3 ARTICLE 230.
4 Section 230-5. The Specialized Mental Health
5 Rehabilitation Act of 2013 is amended by changing Sections
6 5-107 and 5-113 and by adding Section 5-114 as follows:
7 (210 ILCS 49/5-107)
8 Sec. 5-107. Quality of life enhancement. Beginning on July
9 1, 2019, for improving the quality of life and the quality of
10 care, an additional payment shall be awarded to a facility for
11 their single occupancy rooms. This payment shall be in
12 addition to the rate for recovery and rehabilitation. The
13 additional rate for single room occupancy shall be no less
14 than $10 per day, per single room occupancy. The Department of
15 Healthcare and Family Services shall adjust payment to
16 Medicaid managed care entities to cover these costs. Beginning
17 July 1, 2022, for improving the quality of life and the quality
18 of care, a payment of no less than $5 per day, per single room
19 occupancy shall be added to the existing $10 additional per
20 day, per single room occupancy rate for a total of at least $15
21 per day, per single room occupancy. For improving the quality
22 of life and the quality of care, on January 1, 2024, a payment
23 of no less than $10.50 per day, per single room occupancy shall
SB3365 Enrolled - 383 - LRB104 18483 SSS 31925 b
1 be added to the existing $15 additional per day, per single
2 room occupancy rate for a total of at least $25.50 per day, per
3 single room occupancy. For improving the quality of life and
4 the quality of care, beginning on January 1, 2025, a payment of
5 no less than $10 per day, per single room occupancy shall be
6 added to the existing $25.50 additional per day, per single
7 room occupancy rate for a total of at least $35.50 per day, per
8 single room occupancy. For improving the quality of life and
9 the quality of care, beginning on July 1, 2026, a payment of no
10 less than $8 per day, per single room occupancy shall be added
11 to the existing $35.50 additional per day, per single room
12 occupancy rate for a total of at least $43.50 per day, per
13 single room occupancy. Beginning July 1, 2022, for improving
14 the quality of life and the quality of care, an additional
15 payment shall be awarded to a facility for its dual-occupancy
16 rooms. This payment shall be in addition to the rate for
17 recovery and rehabilitation. The additional rate for
18 dual-occupancy rooms shall be no less than $10 per day, per
19 Medicaid-occupied bed, in each dual-occupancy room. Beginning
20 January 1, 2024, for improving the quality of life and the
21 quality of care, a payment of no less than $4.50 per day, per
22 dual-occupancy room shall be added to the existing $10
23 additional per day, per dual-occupancy room rate for a total
24 of at least $14.50, per Medicaid-occupied bed, in each
25 dual-occupancy room. Beginning January 1, 2025, for improving
26 the quality of life and the quality of care, a payment of no
SB3365 Enrolled - 384 - LRB104 18483 SSS 31925 b
1 less than $8.75 per day, per dual-occupancy room shall be
2 added to the existing $14.50 additional per day, per
3 dual-occupancy room rate for a total of at least $23.25, per
4 Medicaid-occupied bed, in each dual-occupancy room. The
5 Department of Healthcare and Family Services shall adjust
6 payment to Medicaid managed care entities to cover these
7 costs. Beginning July 1, 2026, for improving the quality of
8 life and the quality of care, a payment of no less than $2.50
9 per day, per dual-occupancy room shall be added to the
10 existing $23.25 additional per day, per dual-occupancy room
11 rate for a total of at least $25.75, per Medicaid-occupied
12 bed, in each dual-occupancy room. The Department of Healthcare
13 and Family Services shall adjust payment to Medicaid managed
14 care entities to cover these costs. As used in this Section,
15 "dual-occupancy room" means a room that contains 2 resident
16 beds.
17 (Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24;
18 103-593, eff. 6-7-24.)
19 (210 ILCS 49/5-113)
20 Sec. 5-113. Specialized mental health rehabilitation
21 facility; one payment. Notwithstanding any other provision of
22 this Act to the contrary, beginning January 1, 2025, there
23 shall be a separate per diem add-on paid solely and
24 exclusively to facilities licensed under this Act that are
25 licensed for only single occupancy rooms and have reduced
SB3365 Enrolled - 385 - LRB104 18483 SSS 31925 b
1 their licensed capacity. No facility licensed under this Act
2 shall be eligible for these payments if the facility contains
3 any rooms that house more than a single occupant and has have
4 failed to reduce the facility's facilities' licensed capacity.
5 The payment shall be a per diem add-on payment. For
6 facilities with less than 100 licensed beds, the add-on
7 payment shall result in a rate not less than $240 per day. For
8 facilities with 100 licensed beds to 130 licensed beds, the
9 add-on payment shall result in a rate not less than $230 per
10 day. For facilities with more than 130 licensed beds, the
11 add-on payment shall result in a rate of not less than $220 per
12 day. All add-on rates shall be based upon the new licensed
13 capacity.
14 Any additional payments in effect after January 1, 2025
15 under Section 5-107 shall be paid in addition to the amounts
16 listed in this Section. Facilities receiving payments under
17 this Section shall receive payment as prescribed under Section
18 5-101.
19 Beginning July 1, 2026, for facilities with less than 100
20 licensed beds, the payment shall result in a rate not less than
21 $247.50 per day. Beginning July 1, 2026, for facilities with
22 100 licensed beds to 130 licensed beds, the payment shall
23 result in a rate not less than $237.50 per day. For facilities
24 with more than 130 beds, the payment shall result in a rate of
25 no less than $225 per day.
26 (Source: P.A. 103-593, eff. 6-7-24.)
SB3365 Enrolled - 386 - LRB104 18483 SSS 31925 b
1 (210 ILCS 49/5-114 new)
2 Sec. 5-114. Forensic add-on payment. Notwithstanding any
3 other provisions to the contrary, any facility that provides
4 services to a resident found not guilty by reason of insanity
5 and is thereby deemed unable to stand trial shall receive an
6 additional payment of $15 per bed, per day for any resident
7 found not guilty by reason of insanity and is thereby deemed
8 unable to stand trial.
9 ARTICLE 235.
10 Section 235-5. The Department of Human Services Act is
11 amended by adding Section 10-13 as follows:
12 (20 ILCS 1305/10-13 new)
13 Sec. 10-13. Pilot programs with local government entities,
14 nonprofits, or privately funded programs. The Department of
15 Human Services may, subject to appropriation, establish pilot
16 programs through which financial and other support, provided
17 by local governments, nonprofits, or privately funded
18 programs, may be provided to Illinois residents through
19 current or future distribution methods utilized and
20 administered by the Department of Human Services.
21 ARTICLE 240.
SB3365 Enrolled - 387 - LRB104 18483 SSS 31925 b
1 Section 240-5. The Illinois Public Aid Code is amended by
2 adding Section 5-54 as follows:
3 (305 ILCS 5/5-54 new)
4 Sec. 5-54. Coverage for proteomic blood tests.
5 (a) The medical assistance program shall provide coverage
6 and reimbursement for a prescribed proteomic blood test, with
7 clinical trial proof of improved infant outcomes published in
8 peer-reviewed journals, that identifies and quantifies the
9 risk of preterm birth for an individual pregnancy.
10 (b) The medical assistance program shall provide coverage
11 and reimbursement for remote patient management services,
12 including telecare management and remote physiologic
13 monitoring, that address maternity and postpartum care access
14 challenges for individualized care delivery by licensed
15 providers. Only remote patient management services with
16 evidence of improved patient care shall be covered and
17 reimbursed under this subsection.
18 ARTICLE 245.
19 Section 245-5. The Illinois Public Aid Code is amended by
20 adding Section 5-30.19 as follows:
21 (305 ILCS 5/5-30.19 new)
SB3365 Enrolled - 388 - LRB104 18483 SSS 31925 b
1 Sec. 5-30.19. MCO behavioral health post-payment reviews.
2 (a) In this Section:
3 "Extrapolated" shall be used as "extrapolation" is used in
4 89 Ill. Adm. Code 140.30(b) or any successor rule.
5 "Managed care organization" or "MCO" has the meaning given
6 to that term in Section 5-30.1 of this Code.
7 "Post-payment review" means an examination that occurs
8 after payment is made by an MCO for a selected claim to
9 determine whether the initial determination for payment was
10 appropriate.
11 "Provider" means a community mental health center,
12 behavioral health clinic, certified community behavioral
13 health clinic, or substance use treatment and recovery center
14 that is enrolled in the medical assistance program and
15 contracted with or reimbursed by an MCO.
16 (b) Beginning July 1, 2027, when conducting post-payment
17 reviews of providers, MCOs must establish guidelines that
18 follow the Department's guidance. The Department's guidance
19 shall mandate that MCOs:
20 (1) Clearly define the documentation and the response
21 time frames ensuring that all requests are directly tied
22 to the review objectives. Documentation and response time
23 frames do not apply to methods necessary for fraud, waste,
24 and abuse post-payment reviews, including, but not limited
25 to, unscheduled or unannounced site visits and database
26 checks.
SB3365 Enrolled - 389 - LRB104 18483 SSS 31925 b
1 (2) Identify regulatory, statutory, or contractual
2 authority and standards for conducting the post-payment
3 review.
4 (3) Clearly define evaluation criteria and provide
5 documentation checklists.
6 (4) Establish a process to dispute MCO record requests
7 not made in conformance with this Section.
8 (5) Establish a process and clarify the instances that
9 allow for entry and exit communications with providers to
10 clearly convey the review scope, expectations, preliminary
11 findings, compliance status, and next steps, ensuring
12 consistent messaging throughout the review process.
13 (6) Establish qualifications of reviewers with
14 relevant knowledge, experience, and training.
15 (7) Provide the data on how the provider varies
16 significantly from other providers in the same provider
17 type, service specialty, jurisdiction, or locality, if the
18 basis for selection of a provider for review is
19 comparative data except where fraud, waste, and abuse
20 processes and procedures prevent disclosure.
21 (8) Clearly outline communication protocols, including
22 advance written notice, delivered electronically, by MCOs
23 to providers of documentation requests with an allowance
24 for reasonable response times and except for instances
25 where fraud, waste, and abuse processes and procedures
26 prevent advance notice, including, but not limited to,
SB3365 Enrolled - 390 - LRB104 18483 SSS 31925 b
1 unscheduled or unannounced site visits.
2 (9) Upon completion of the review, issue a formal
3 written notice of compliance or closure to the provider.
4 The final review findings shall include clear references
5 to applicable regulatory or contractual citations, an
6 explanation of the rationale for each finding, guidance on
7 required next steps or corrective actions, and information
8 regarding the process and timelines for appealing the
9 findings.
10 (10) Use the least burdensome and lowest-cost method
11 of record submission, including secure electronic methods,
12 when available. The date on which documentation is
13 received in the electronic communication shall be the
14 official date of receipt. All communication protocols
15 shall be compliant with privacy and security laws.
16 (11) Issue findings and related written communications
17 in a clear, consistent, and non-contradictory manner to
18 prevent confusion or conflicting conclusions.
19 (12) Disclose the methodology supporting any
20 extrapolated finding.
21 (c) The MCO shall post the guidelines and any updates on
22 its publicly available website.
23 (d) Providers must not be subject to any adverse action,
24 payment delay, sanctions, or contract termination solely for
25 exercising the right to dispute a records request in
26 accordance with this Section, except for matters involving
SB3365 Enrolled - 391 - LRB104 18483 SSS 31925 b
1 allegations of fraud, waste, or abuse.
2 (e) Nothing in this Section shall be construed to conflict
3 with State or federal program integrity law, regulations,
4 guidance, processes, or procedures.
5 ARTICLE 250.
6 Section 250-5. The Illinois Public Aid Code is amended by
7 adding Section 5-70 as follows:
8 (305 ILCS 5/5-70 new)
9 Sec. 5-70. Virtual intensive outpatient program services.
10 For dates of service on and after January 1, 2027, subject to
11 any necessary federal approval, the medical assistance program
12 shall provide coverage for virtual intensive outpatient
13 program services when clinically appropriate, delivered in
14 line with generally accepted standards of care, and only at
15 the request of or with the consent of the patient. The
16 Department shall establish provider qualifications for
17 intensive outpatient program services offering a virtual
18 service delivery option. The Department may establish
19 utilization controls and any appropriate guidelines for
20 coverage of the virtual intensive outpatient program to
21 protect the well-being of persons eligible and enrolled in the
22 medical assistance program. The Department may adopt rules
23 necessary to implement this Section.
SB3365 Enrolled - 392 - LRB104 18483 SSS 31925 b
1 ARTICLE 255.
2 Section 255-5. The Illinois Public Aid Code is amended by
3 changing Section 5-5.01a as follows:
4 (305 ILCS 5/5-5.01a)
5 Sec. 5-5.01a. Supportive living facilities program.
6 (a) The Department shall establish and provide oversight
7 for a program of supportive living facilities that seek to
8 promote resident independence, dignity, respect, and
9 well-being in the most cost-effective manner.
10 A supportive living facility is (i) a free-standing
11 facility or (ii) a distinct physical and operational entity
12 within a mixed-use building that meets the criteria
13 established in subsection (d). A supportive living facility
14 integrates housing with health, personal care, and supportive
15 services and is a designated setting that offers residents
16 their own separate, private, and distinct living units.
17 Sites for the operation of the program shall be selected
18 by the Department based upon criteria that may include the
19 need for services in a geographic area, the availability of
20 funding, and the site's ability to meet the standards.
21 (b) Beginning July 1, 2014, subject to federal approval,
22 the Medicaid rates for supportive living facilities shall be
23 equal to the supportive living facility Medicaid rate
SB3365 Enrolled - 393 - LRB104 18483 SSS 31925 b
1 effective on June 30, 2014 increased by 8.85%. Once the
2 assessment imposed at Article V-G of this Code is determined
3 to be a permissible tax under Title XIX of the Social Security
4 Act, the Department shall increase the Medicaid rates for
5 supportive living facilities effective on July 1, 2014 by
6 9.09%. The Department shall apply this increase retroactively
7 to coincide with the imposition of the assessment in Article
8 V-G of this Code in accordance with the approval for federal
9 financial participation by the Centers for Medicare and
10 Medicaid Services.
11 The Medicaid rates for supportive living facilities
12 effective on July 1, 2017 must be equal to the rates in effect
13 for supportive living facilities on June 30, 2017 increased by
14 2.8%.
15 The Medicaid rates for supportive living facilities
16 effective on July 1, 2018 must be equal to the rates in effect
17 for supportive living facilities on June 30, 2018.
18 Subject to federal approval, the Medicaid rates for
19 supportive living services on and after July 1, 2019 must be at
20 least 54.3% of the average total nursing facility services per
21 diem for the geographic areas defined by the Department while
22 maintaining the rate differential for dementia care and must
23 be updated whenever the total nursing facility service per
24 diems are updated. Beginning July 1, 2022, upon the
25 implementation of the Patient Driven Payment Model, Medicaid
26 rates for supportive living services must be at least 54.3% of
SB3365 Enrolled - 394 - LRB104 18483 SSS 31925 b
1 the average total nursing services per diem rate for the
2 geographic areas. For purposes of this provision, the average
3 total nursing services per diem rate shall include all add-ons
4 for nursing facilities for the geographic area provided for in
5 Section 5-5.2. The rate differential for dementia care must be
6 maintained in these rates and the rates shall be updated
7 whenever nursing facility per diem rates are updated.
8 Subject to federal approval, beginning January 1, 2024,
9 the dementia care rate for supportive living services must be
10 no less than the non-dementia care supportive living services
11 rate multiplied by 1.5.
12 (b-5) Subject to federal approval, beginning January 1,
13 2025, Medicaid rates for supportive living services must be at
14 least 54.75% of the average total nursing facility per diem
15 rate for the geographic areas defined by the Department and
16 shall include all add-ons for nursing facilities for the
17 geographic area provided for in Section 5-5.2.
18 (c) The Department may adopt rules to implement this
19 Section. Rules that establish or modify the services,
20 standards, and conditions for participation in the program
21 shall be adopted by the Department in consultation with the
22 Department on Aging, the Department of Rehabilitation
23 Services, and the Department of Mental Health and
24 Developmental Disabilities (or their successor agencies).
25 (d) Subject to federal approval by the Centers for
26 Medicare and Medicaid Services, the Department shall accept
SB3365 Enrolled - 395 - LRB104 18483 SSS 31925 b
1 for consideration of certification under the program any
2 application for a site or building where distinct parts of the
3 site or building are designated for purposes other than the
4 provision of supportive living services, but only if:
5 (1) those distinct parts of the site or building are
6 not designated for the purpose of providing assisted
7 living services as required under the Assisted Living and
8 Shared Housing Act;
9 (2) those distinct parts of the site or building are
10 completely separate from the part of the building used for
11 the provision of supportive living program services,
12 including separate entrances;
13 (3) those distinct parts of the site or building do
14 not share any common spaces with the part of the building
15 used for the provision of supportive living program
16 services; and
17 (4) those distinct parts of the site or building do
18 not share staffing with the part of the building used for
19 the provision of supportive living program services.
20 (e) Facilities or distinct parts of facilities which are
21 selected as supportive living facilities and are in good
22 standing with the Department's rules are exempt from the
23 provisions of the Nursing Home Care Act and the Illinois
24 Health Facilities Planning Act.
25 (f) Section 9817 of the American Rescue Plan Act of 2021
26 (Public Law 117-2) authorizes a 10% enhanced federal medical
SB3365 Enrolled - 396 - LRB104 18483 SSS 31925 b
1 assistance percentage for supportive living services for a
2 12-month period from April 1, 2021 through March 31, 2022.
3 Subject to federal approval, including the approval of any
4 necessary waiver amendments or other federally required
5 documents or assurances, for a 12-month period the Department
6 must pay a supplemental $26 per diem rate to all supportive
7 living facilities with the additional federal financial
8 participation funds that result from the enhanced federal
9 medical assistance percentage from April 1, 2021 through March
10 31, 2022. The Department may issue parameters around how the
11 supplemental payment should be spent, including quality
12 improvement activities. The Department may alter the form,
13 methods, or timeframes concerning the supplemental per diem
14 rate to comply with any subsequent changes to federal law,
15 changes made by guidance issued by the federal Centers for
16 Medicare and Medicaid Services, or other changes necessary to
17 receive the enhanced federal medical assistance percentage.
18 (g) All applications for the expansion of supportive
19 living dementia care settings involving sites not approved by
20 the Department by January 1, 2024 may allow new elderly
21 non-dementia units in addition to new dementia care units. The
22 Department may approve such applications only if the
23 application has: (1) no more than one non-dementia care unit
24 for each dementia care unit and (2) the site is not located
25 within 4 miles of an existing supportive living program site
26 in Cook County (including the City of Chicago), not located
SB3365 Enrolled - 397 - LRB104 18483 SSS 31925 b
1 within 12 miles of an existing supportive living program site
2 in Alexander, Bond, Boone, Calhoun, Champaign, Clinton,
3 DeKalb, DuPage, Fulton, Grundy, Henry, Jackson, Jersey,
4 Johnson, Kane, Kankakee, Kendall, Lake, Macon, Macoupin,
5 Madison, Marshall, McHenry, McLean, Menard, Mercer, Monroe,
6 Peoria, Piatt, Rock Island, Sangamon, Stark, St. Clair,
7 Tazewell, Vermilion, Will, Williamson, Winnebago, or Woodford
8 counties, or not located within 25 miles of an existing
9 supportive living program site in any other county.
10 (g-5) Subject to federal approval, beginning January 1,
11 2027, any individual age 44 to 64 who is diagnosed as having
12 Alzheimer's disease or a related dementia and is determined to
13 be a person with a disability by the Social Security
14 Administration shall be eligible for services in a supportive
15 living dementia care setting if the individual meets all other
16 eligibility requirements to receive services in a supportive
17 living dementia care setting under 89 Ill. Adm. Code 146
18 Subpart B and E. The Department shall apply for any federal
19 waiver necessary to implement this subsection.
20 (h) Beginning January 1, 2025, subject to federal
21 approval, for a person who is a resident of a supportive living
22 facility under this Section, the monthly personal needs
23 allowance shall be $120 per month.
24 (i) As stated in the supportive living program home and
25 community-based service waiver approved by the federal Centers
26 for Medicare and Medicaid Services, and beginning July 1,
SB3365 Enrolled - 398 - LRB104 18483 SSS 31925 b
1 2025, the Department must maintain the rate add-on implemented
2 on January 1, 2023 for the provision of 2 meals per day at no
3 less than $6.15 per day.
4 (j) Subject to federal approval, the Department shall
5 allow a certified medication aide to administer medication in
6 a supportive living facility. For purposes of this subsection,
7 "certified medication aide" means a person who has met the
8 qualifications for certification under Section 79 of the
9 Assisted Living and Shared Housing Act and assists with
10 medication administration while under the supervision of a
11 registered professional nurse as authorized by Section 50-75
12 of the Nurse Practice Act. The Department may adopt rules to
13 implement this subsection.
14 (Source: P.A. 103-102, Article 20, Section 20-5, eff. 1-1-24;
15 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593,
16 Article 15, Section 15-5, eff. 6-7-24; 103-593, Article 100,
17 Section 100-5, eff. 6-7-24; 103-593, Article 165, Section
18 165-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-886, eff.
19 8-9-24; 104-9, eff. 6-16-25; 104-417, eff. 8-15-25; revised
20 9-12-25.)
21 ARTICLE 257.
22 Section 257-3. The Department of Public Health Powers and
23 Duties Law is amended by adding Section 2310-716 as follows:
SB3365 Enrolled - 399 - LRB104 18483 SSS 31925 b
1 (20 ILCS 2310/2310-716 new)
2 Sec. 2310-716. Report on patient access and care. With a
3 health care landscape shifting dramatically from inpatient,
4 volume-drive care to more outpatient, community-faced care and
5 further exacerbated by HR1 changes that disinvests billions of
6 dollars from the health care system and increase uninsured
7 populations, the Department of Public Health, in partnership
8 with relevant State agencies and with the advice of
9 stakeholders and experts in the field, shall develop a
10 comprehensive report that identifies how the resources of the
11 State and other health care payers may be optimized to protect
12 communities' and patients' access and care and to improve
13 Illinois' population health outcomes.
14 The Department may engage a third-party experienced and
15 expert research entity to develop this report. The report
16 shall include analysis, findings, and recommendations to
17 reform and strengthen the health care system in Illinois. The
18 report will have emphasis on the needs and vulnerabilities
19 experienced by individuals living in communities with limited
20 access to critical health care services.
21 The report will include epidemiological analyses and
22 recommendations on policy and resource strategies to protect
23 and improve population health outcomes and health care access
24 including but not limited to:
25 (1) Patient experience that includes social needs
26 integration, reduced administrative burden, and enhanced
SB3365 Enrolled - 400 - LRB104 18483 SSS 31925 b
1 digital tools.
2 (2) Care model transformation that emphasizes
3 continuous, community-based care built to address health
4 access gaps and needs.
5 (3) Workforce resilience and optimization that
6 highlights partnership and care-delivery opportunities
7 across institutions.
8 (4) System agility to absorb and recover from
9 unforeseen public health crises and other external
10 factors.
11 The Department shall have access to all the necessary data
12 from State agencies as well as health care facilities as
13 required to inform on these recommendations, within the bounds
14 of relevance to their mission. Health care facilities will
15 hereby be directed to provide the necessary data to the
16 Department.
17 The Department shall issue recommendations to the General
18 Assembly and the Governor no later than January 31, 2027,
19 including proposed statutory or administrative changes
20 necessary to strengthen health care access, quality, and
21 effectiveness.
22 (20 ILCS 2310/2310-715 rep.)
23 Section 257-5. The Department of Public Health Powers and
24 Duties Law of the Civil Administrative Code of Illinois is
25 amended by repealing Section 2310-715.
SB3365 Enrolled - 401 - LRB104 18483 SSS 31925 b
1 Section 257-10. The Illinois Public Aid Code is amended by
2 changing Sections 5A-2, 5A-7, 5A-8, and 12-4.25 as follows:
3 (305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)
4 Sec. 5A-2. Assessment.
5 (a)(1) Subject to Sections 5A-3 and 5A-10, for State
6 fiscal years 2009 through 2018, or as long as continued under
7 Section 5A-16, an annual assessment on inpatient services is
8 imposed on each hospital provider in an amount equal to
9 $218.38 multiplied by the difference of the hospital's
10 occupied bed days less the hospital's Medicare bed days,
11 provided, however, that the amount of $218.38 shall be
12 increased by a uniform percentage to generate an amount equal
13 to 75% of the State share of the payments authorized under
14 Section 5A-12.5, with such increase only taking effect upon
15 the date that a State share for such payments is required under
16 federal law. For the period of April through June 2015, the
17 amount of $218.38 used to calculate the assessment under this
18 paragraph shall, by emergency rule under subsection (s) of
19 Section 5-45 of the Illinois Administrative Procedure Act, be
20 increased by a uniform percentage to generate $20,250,000 in
21 the aggregate for that period from all hospitals subject to
22 the annual assessment under this paragraph.
23 (2) In addition to any other assessments imposed under
24 this Article, effective July 1, 2016 and semi-annually
SB3365 Enrolled - 402 - LRB104 18483 SSS 31925 b
1 thereafter through June 2018, or as provided in Section 5A-16,
2 in addition to any federally required State share as
3 authorized under paragraph (1), the amount of $218.38 shall be
4 increased by a uniform percentage to generate an amount equal
5 to 75% of the ACA Assessment Adjustment, as defined in
6 subsection (b-6) of this Section.
7 For State fiscal years 2009 through 2018, or as provided
8 in Section 5A-16, a hospital's occupied bed days and Medicare
9 bed days shall be determined using the most recent data
10 available from each hospital's 2005 Medicare cost report as
11 contained in the Healthcare Cost Report Information System
12 file, for the quarter ending on December 31, 2006, without
13 regard to any subsequent adjustments or changes to such data.
14 If a hospital's 2005 Medicare cost report is not contained in
15 the Healthcare Cost Report Information System, then the
16 Illinois Department may obtain the hospital provider's
17 occupied bed days and Medicare bed days from any source
18 available, including, but not limited to, records maintained
19 by the hospital provider, which may be inspected at all times
20 during business hours of the day by the Illinois Department or
21 its duly authorized agents and employees.
22 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
23 fiscal years 2019 and 2020, an annual assessment on inpatient
24 services is imposed on each hospital provider in an amount
25 equal to $197.19 multiplied by the difference of the
26 hospital's occupied bed days less the hospital's Medicare bed
SB3365 Enrolled - 403 - LRB104 18483 SSS 31925 b
1 days. For State fiscal years 2019 and 2020, a hospital's
2 occupied bed days and Medicare bed days shall be determined
3 using the most recent data available from each hospital's 2015
4 Medicare cost report as contained in the Healthcare Cost
5 Report Information System file, for the quarter ending on
6 March 31, 2017, without regard to any subsequent adjustments
7 or changes to such data. If a hospital's 2015 Medicare cost
8 report is not contained in the Healthcare Cost Report
9 Information System, then the Illinois Department may obtain
10 the hospital provider's occupied bed days and Medicare bed
11 days from any source available, including, but not limited to,
12 records maintained by the hospital provider, which may be
13 inspected at all times during business hours of the day by the
14 Illinois Department or its duly authorized agents and
15 employees. Notwithstanding any other provision in this
16 Article, for a hospital provider that did not have a 2015
17 Medicare cost report, but paid an assessment in State fiscal
18 year 2018 on the basis of hypothetical data, that assessment
19 amount shall be used for State fiscal years 2019 and 2020.
20 (4) Subject to Sections 5A-3 and 5A-10 and to subsection
21 (b-8), for the period of July 1, 2020 through December 31, 2020
22 and calendar years 2021 through 2024, an annual assessment on
23 inpatient services is imposed on each hospital provider in an
24 amount equal to $221.50 multiplied by the difference of the
25 hospital's occupied bed days less the hospital's Medicare bed
26 days, provided however: for the period of July 1, 2020 through
SB3365 Enrolled - 404 - LRB104 18483 SSS 31925 b
1 December 31, 2020, (i) the assessment shall be equal to 50% of
2 the annual amount; and (ii) the amount of $221.50 shall be
3 retroactively adjusted by a uniform percentage to generate an
4 amount equal to 50% of the Assessment Adjustment, as defined
5 in subsection (b-7). For the period of July 1, 2020 through
6 December 31, 2020 and calendar years 2021 through 2024, a
7 hospital's occupied bed days and Medicare bed days shall be
8 determined using the most recent data available from each
9 hospital's 2015 Medicare cost report as contained in the
10 Healthcare Cost Report Information System file, for the
11 quarter ending on March 31, 2017, without regard to any
12 subsequent adjustments or changes to such data. If a
13 hospital's 2015 Medicare cost report is not contained in the
14 Healthcare Cost Report Information System, then the Illinois
15 Department may obtain the hospital provider's occupied bed
16 days and Medicare bed days from any source available,
17 including, but not limited to, records maintained by the
18 hospital provider, which may be inspected at all times during
19 business hours of the day by the Illinois Department or its
20 duly authorized agents and employees. Should the change in the
21 assessment methodology for fiscal years 2021 through December
22 31, 2022 not be approved on or before June 30, 2020, the
23 assessment and payments under this Article in effect for
24 fiscal year 2020 shall remain in place until the new
25 assessment is approved. If the assessment methodology for July
26 1, 2020 through December 31, 2022, is approved on or after July
SB3365 Enrolled - 405 - LRB104 18483 SSS 31925 b
1 1, 2020, it shall be retroactive to July 1, 2020, subject to
2 federal approval and provided that the payments authorized
3 under Section 5A-12.7 have the same effective date as the new
4 assessment methodology. In giving retroactive effect to the
5 assessment approved after June 30, 2020, credit toward the new
6 assessment shall be given for any payments of the previous
7 assessment for periods after June 30, 2020. Notwithstanding
8 any other provision of this Article, for a hospital provider
9 that did not have a 2015 Medicare cost report, but paid an
10 assessment in State Fiscal Year 2020 on the basis of
11 hypothetical data, the data that was the basis for the 2020
12 assessment shall be used to calculate the assessment under
13 this paragraph until December 31, 2023. Beginning July 1, 2022
14 and through December 31, 2024, a safety-net hospital that had
15 a change of ownership in calendar year 2021, and whose
16 inpatient utilization had decreased by 90% from the prior year
17 and prior to the change of ownership, may be eligible to pay a
18 tax based on hypothetical data based on a determination of
19 financial distress by the Department. Subject to federal
20 approval, the Department may, by January 1, 2024, develop a
21 hypothetical tax for a specialty cancer hospital which had a
22 structural change of ownership during calendar year 2022 from
23 a for-profit entity to a non-profit entity, and which has
24 experienced a decline of 60% or greater in inpatient days of
25 care as compared to the prior owners 2015 Medicare cost
26 report. This change of ownership may make the hospital
SB3365 Enrolled - 406 - LRB104 18483 SSS 31925 b
1 eligible for a hypothetical tax under the new hospital
2 provision of the assessment defined in this Section. This new
3 hypothetical tax may be applicable from January 1, 2024
4 through December 31, 2026.
5 (5) Subject to Sections 5A-3 and 5A-10, beginning January
6 1, 2025, an annual assessment on inpatient services is imposed
7 on each hospital provider in an amount equal to $362, or any
8 reduction thereof in accordance with this subsection,
9 multiplied by the difference of the hospital's occupied bed
10 days less the hospital's Medicare bed days; however, the rate
11 shall be $221.50 until the Department receives federal
12 approval and implements the reimbursement rates in subsection
13 (r) of Section 5A-12.7. The Department may bill for the
14 difference between the assessment rate of $362, or any
15 reduction thereof in accordance with this subsection, and
16 $221.50 no earlier than 17 calendar days after implementing
17 the reimbursement rates in subsection (r) of Section 5A-12.7.
18 (A) Upon receiving federal approval for the
19 reimbursement rates in subsection (r) of Section 5A-12.7,
20 the Department shall bill the hospital for the incremental
21 difference in total tax due resulting from the increase
22 provided in this subsection for the number of months from
23 January 1, 2025 through the date of federal approval. The
24 amount shall be due and payable no later than December 31,
25 2025 and no earlier than 17 calendar days after
26 implementing the reimbursement rates in subsection (r) of
SB3365 Enrolled - 407 - LRB104 18483 SSS 31925 b
1 Section 5A-12.7. The Department shall bill hospitals in
2 the same proportional rate as the Department has
3 implemented the inpatient reimbursement rates in
4 subsection (r) of Section 5A-12.7.
5 (B) Beginning January 1, 2025, a hospital's occupied
6 bed days and Medicare bed days shall be determined using
7 the most recent data available from each hospital's 2015
8 Medicare cost report as contained in the Healthcare Cost
9 Report Information System file, for the quarter ending on
10 March 31, 2017, without regard to any subsequent
11 adjustments or changes to such data. If a hospital's 2015
12 Medicare cost report is not contained in the Healthcare
13 Cost Report Information System, then the Department may
14 obtain the hospital provider's occupied bed days and
15 Medicare bed days from any source available, including,
16 but not limited to, records maintained by the hospital
17 provider, which may be inspected at all times during
18 business hours of the day by the Department or its duly
19 authorized agents and employees. If the reimbursement
20 rates in subsection (r) of Section 5A-12.7 require
21 reduction to comply with federal spending limits, then the
22 tax rate of $362 shall be reduced, in accordance with
23 subsection (s) of Section 5A-12.7, by the same percentage
24 reduction to payments required to comply with federal
25 spending limits.
26 (6) For calendar year 2026, and for each year thereafter
SB3365 Enrolled - 408 - LRB104 18483 SSS 31925 b
1 in which a tax is imposed under this Section, the Department
2 may seek to obtain a waiver from the federal Centers for
3 Medicare and Medicaid Services of the uniformity requirements
4 in place for the tax imposed under this Section, provided that
5 such waiver request does not risk the assessment imposed or
6 payments authorized under this Section from continuing. Such
7 uniformity requirements shall only be waived for
8 not-for-profit hospitals operating as a freestanding cancer
9 hospital that have contracted to provide services to members
10 served by at least 50% of the managed care organizations
11 contracted with the Department. Such tax rates imposed on a
12 hospital shall be no more than 50% and no less than 25% of the
13 tax imposed on all other hospitals in this State unless
14 different rates are necessary to meet federal statistical
15 tests necessary for continued federal financial participation.
16 Upon federal approval of such a waiver, other tax rates
17 imposed under this Article shall be adjusted to ensure budget
18 neutrality.
19 (b) (Blank).
20 (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
21 portion of State fiscal year 2012, beginning June 10, 2012
22 through June 30, 2012, and for State fiscal years 2013 through
23 2018, or as provided in Section 5A-16, an annual assessment on
24 outpatient services is imposed on each hospital provider in an
25 amount equal to .008766 multiplied by the hospital's
26 outpatient gross revenue, provided, however, that the amount
SB3365 Enrolled - 409 - LRB104 18483 SSS 31925 b
1 of .008766 shall be increased by a uniform percentage to
2 generate an amount equal to 25% of the State share of the
3 payments authorized under Section 5A-12.5, with such increase
4 only taking effect upon the date that a State share for such
5 payments is required under federal law. For the period
6 beginning June 10, 2012 through June 30, 2012, the annual
7 assessment on outpatient services shall be prorated by
8 multiplying the assessment amount by a fraction, the numerator
9 of which is 21 days and the denominator of which is 365 days.
10 For the period of April through June 2015, the amount of
11 .008766 used to calculate the assessment under this paragraph
12 shall, by emergency rule under subsection (s) of Section 5-45
13 of the Illinois Administrative Procedure Act, be increased by
14 a uniform percentage to generate $6,750,000 in the aggregate
15 for that period from all hospitals subject to the annual
16 assessment under this paragraph.
17 (2) In addition to any other assessments imposed under
18 this Article, effective July 1, 2016 and semi-annually
19 thereafter through June 2018, in addition to any federally
20 required State share as authorized under paragraph (1), the
21 amount of .008766 shall be increased by a uniform percentage
22 to generate an amount equal to 25% of the ACA Assessment
23 Adjustment, as defined in subsection (b-6) of this Section.
24 For the portion of State fiscal year 2012, beginning June
25 10, 2012 through June 30, 2012, and State fiscal years 2013
26 through 2018, or as provided in Section 5A-16, a hospital's
SB3365 Enrolled - 410 - LRB104 18483 SSS 31925 b
1 outpatient gross revenue shall be determined using the most
2 recent data available from each hospital's 2009 Medicare cost
3 report as contained in the Healthcare Cost Report Information
4 System file, for the quarter ending on June 30, 2011, without
5 regard to any subsequent adjustments or changes to such data.
6 If a hospital's 2009 Medicare cost report is not contained in
7 the Healthcare Cost Report Information System, then the
8 Department may obtain the hospital provider's outpatient gross
9 revenue from any source available, including, but not limited
10 to, records maintained by the hospital provider, which may be
11 inspected at all times during business hours of the day by the
12 Department or its duly authorized agents and employees.
13 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
14 fiscal years 2019 and 2020, an annual assessment on outpatient
15 services is imposed on each hospital provider in an amount
16 equal to .01358 multiplied by the hospital's outpatient gross
17 revenue. For State fiscal years 2019 and 2020, a hospital's
18 outpatient gross revenue shall be determined using the most
19 recent data available from each hospital's 2015 Medicare cost
20 report as contained in the Healthcare Cost Report Information
21 System file, for the quarter ending on March 31, 2017, without
22 regard to any subsequent adjustments or changes to such data.
23 If a hospital's 2015 Medicare cost report is not contained in
24 the Healthcare Cost Report Information System, then the
25 Department may obtain the hospital provider's outpatient gross
26 revenue from any source available, including, but not limited
SB3365 Enrolled - 411 - LRB104 18483 SSS 31925 b
1 to, records maintained by the hospital provider, which may be
2 inspected at all times during business hours of the day by the
3 Department or its duly authorized agents and employees.
4 Notwithstanding any other provision in this Article, for a
5 hospital provider that did not have a 2015 Medicare cost
6 report, but paid an assessment in State fiscal year 2018 on the
7 basis of hypothetical data, that assessment amount shall be
8 used for State fiscal years 2019 and 2020.
9 (4) Subject to Sections 5A-3 and 5A-10 and to subsection
10 (b-8), for the period of July 1, 2020 through December 31, 2020
11 and calendar years 2021 through 2024, an annual assessment on
12 outpatient services is imposed on each hospital provider in an
13 amount equal to .01525 multiplied by the hospital's outpatient
14 gross revenue, provided however: (i) for the period of July 1,
15 2020 through December 31, 2020, the assessment shall be equal
16 to 50% of the annual amount; and (ii) the amount of .01525
17 shall be retroactively adjusted by a uniform percentage to
18 generate an amount equal to 50% of the Assessment Adjustment,
19 as defined in subsection (b-7). For the period of July 1, 2020
20 through December 31, 2020 and calendar years 2021 through
21 2024, a hospital's outpatient gross revenue shall be
22 determined using the most recent data available from each
23 hospital's 2015 Medicare cost report as contained in the
24 Healthcare Cost Report Information System file, for the
25 quarter ending on March 31, 2017, without regard to any
26 subsequent adjustments or changes to such data. If a
SB3365 Enrolled - 412 - LRB104 18483 SSS 31925 b
1 hospital's 2015 Medicare cost report is not contained in the
2 Healthcare Cost Report Information System, then the Illinois
3 Department may obtain the hospital provider's outpatient
4 revenue data from any source available, including, but not
5 limited to, records maintained by the hospital provider, which
6 may be inspected at all times during business hours of the day
7 by the Illinois Department or its duly authorized agents and
8 employees. Should the change in the assessment methodology
9 above for fiscal years 2021 through calendar year 2022 not be
10 approved prior to July 1, 2020, the assessment and payments
11 under this Article in effect for fiscal year 2020 shall remain
12 in place until the new assessment is approved. If the change in
13 the assessment methodology above for July 1, 2020 through
14 December 31, 2022, is approved after June 30, 2020, it shall
15 have a retroactive effective date of July 1, 2020, subject to
16 federal approval and provided that the payments authorized
17 under Section 12A-7 have the same effective date as the new
18 assessment methodology. In giving retroactive effect to the
19 assessment approved after June 30, 2020, credit toward the new
20 assessment shall be given for any payments of the previous
21 assessment for periods after June 30, 2020. Notwithstanding
22 any other provision of this Article, for a hospital provider
23 that did not have a 2015 Medicare cost report, but paid an
24 assessment in State Fiscal Year 2020 on the basis of
25 hypothetical data, the data that was the basis for the 2020
26 assessment shall be used to calculate the assessment under
SB3365 Enrolled - 413 - LRB104 18483 SSS 31925 b
1 this paragraph until December 31, 2023. Beginning July 1, 2022
2 and through December 31, 2024, a safety-net hospital that had
3 a change of ownership in calendar year 2021, and whose
4 inpatient utilization had decreased by 90% from the prior year
5 and prior to the change of ownership, may be eligible to pay a
6 tax based on hypothetical data based on a determination of
7 financial distress by the Department.
8 (5) Subject to Sections 5A-3 and 5A-10, beginning January
9 1, 2025, an annual assessment on outpatient services is
10 imposed on each hospital provider in an amount equal to
11 .03273, or any reduction thereof in accordance with this
12 subsection, multiplied by the hospital's outpatient gross
13 revenue; however the rate shall remain .01525, until the
14 Department receives federal approval and implements the
15 reimbursement rates of payment in subsection (r) of Section
16 5A-12.7. The Department may bill for the difference between
17 the assessment multiplier of .03273 and .01525 no earlier than
18 17 calendar days after the first payment based on the
19 reimbursement rates in subsection (r) of Section 5A-12.7.
20 (A) Upon receiving federal approval for the
21 reimbursement rates in subsection (r) of Section 5A-12.7,
22 the Department shall bill the hospital for the incremental
23 difference in total tax due resulting from the increase
24 provided in this subsection for the number of months from
25 January 1, 2025 through the date of federal approval. The
26 amount shall be due and payable no later than December 31,
SB3365 Enrolled - 414 - LRB104 18483 SSS 31925 b
1 2025 and no earlier than 17 calendar days after
2 implementing the reimbursement rates in subsection (r) of
3 Section 5A-12.7. The Department shall bill hospitals in
4 the same proportional rate as the Department has
5 implemented the outpatient reimbursement rates in
6 subsection (r) of Section 5A-12.7.
7 (B) Beginning January 1, 2025, a hospital's outpatient
8 gross revenue shall be determined using the most recent
9 data available from each hospital's 2015 Medicare cost
10 report as contained in the Healthcare Cost Report
11 Information System file, for the quarter ending on March
12 31, 2017, without regard to any subsequent adjustments or
13 changes to such data. If a hospital's 2015 Medicare cost
14 report is not contained in the Healthcare Cost Report
15 Information System, then the Department may obtain the
16 hospital provider's outpatient revenue data from any
17 source available, including, but not limited to, records
18 maintained by the hospital provider, which may be
19 inspected at all times during business hours of the day by
20 the Department or its duly authorized agents and
21 employees. If the reimbursement rates in subsection (r) of
22 Section 5A-12.7 require reduction to comply with federal
23 spending limits, then the tax rate of .03273 shall be
24 reduced, in accordance with subsection (s) of Section
25 5A-12.7, by the same percentage reduction to payments
26 required to comply with federal spending limits.
SB3365 Enrolled - 415 - LRB104 18483 SSS 31925 b
1 (6) For calendar year 2026, and for each year thereafter
2 in which a tax is imposed under this Section, the Department
3 may seek to obtain a waiver from the federal Centers for
4 Medicare and Medicaid Services of the uniformity requirements
5 in place for the tax imposed under this Section, provided that
6 such waiver request does not risk the assessment imposed or
7 payments authorized under this Section from continuing. Such
8 uniformity requirements shall only be waived for
9 not-for-profit hospitals operating as a freestanding cancer
10 hospital that have contracted to provide services to members
11 served by at least 50% of the managed care organizations
12 contracted with the Department. Such tax rates imposed on a
13 hospital shall be no more than 50% and no less than 25% of the
14 tax imposed on all other hospitals in this State unless
15 different rates are necessary to meet federal statistical
16 tests necessary for continued federal financial participation.
17 Upon federal approval of such a waiver, other tax rates
18 imposed under this Article shall be adjusted to ensure budget
19 neutrality.
20 (b-6)(1) As used in this Section, "ACA Assessment
21 Adjustment" means:
22 (A) For the period of July 1, 2016 through December
23 31, 2016, the product of .19125 multiplied by the sum of
24 the fee-for-service payments to hospitals as authorized
25 under Section 5A-12.5 and the adjustments authorized under
26 subsection (t) of Section 5A-12.2 to managed care
SB3365 Enrolled - 416 - LRB104 18483 SSS 31925 b
1 organizations for hospital services due and payable in the
2 month of April 2016 multiplied by 6.
3 (B) For the period of January 1, 2017 through June 30,
4 2017, the product of .19125 multiplied by the sum of the
5 fee-for-service payments to hospitals as authorized under
6 Section 5A-12.5 and the adjustments authorized under
7 subsection (t) of Section 5A-12.2 to managed care
8 organizations for hospital services due and payable in the
9 month of October 2016 multiplied by 6, except that the
10 amount calculated under this subparagraph (B) shall be
11 adjusted, either positively or negatively, to account for
12 the difference between the actual payments issued under
13 Section 5A-12.5 for the period beginning July 1, 2016
14 through December 31, 2016 and the estimated payments due
15 and payable in the month of April 2016 multiplied by 6 as
16 described in subparagraph (A).
17 (C) For the period of July 1, 2017 through December
18 31, 2017, the product of .19125 multiplied by the sum of
19 the fee-for-service payments to hospitals as authorized
20 under Section 5A-12.5 and the adjustments authorized under
21 subsection (t) of Section 5A-12.2 to managed care
22 organizations for hospital services due and payable in the
23 month of April 2017 multiplied by 6, except that the
24 amount calculated under this subparagraph (C) shall be
25 adjusted, either positively or negatively, to account for
26 the difference between the actual payments issued under
SB3365 Enrolled - 417 - LRB104 18483 SSS 31925 b
1 Section 5A-12.5 for the period beginning January 1, 2017
2 through June 30, 2017 and the estimated payments due and
3 payable in the month of October 2016 multiplied by 6 as
4 described in subparagraph (B).
5 (D) For the period of January 1, 2018 through June 30,
6 2018, the product of .19125 multiplied by the sum of the
7 fee-for-service payments to hospitals as authorized under
8 Section 5A-12.5 and the adjustments authorized under
9 subsection (t) of Section 5A-12.2 to managed care
10 organizations for hospital services due and payable in the
11 month of October 2017 multiplied by 6, except that:
12 (i) the amount calculated under this subparagraph
13 (D) shall be adjusted, either positively or
14 negatively, to account for the difference between the
15 actual payments issued under Section 5A-12.5 for the
16 period of July 1, 2017 through December 31, 2017 and
17 the estimated payments due and payable in the month of
18 April 2017 multiplied by 6 as described in
19 subparagraph (C); and
20 (ii) the amount calculated under this subparagraph
21 (D) shall be adjusted to include the product of .19125
22 multiplied by the sum of the fee-for-service payments,
23 if any, estimated to be paid to hospitals under
24 subsection (b) of Section 5A-12.5.
25 (2) The Department shall complete and apply a final
26 reconciliation of the ACA Assessment Adjustment prior to June
SB3365 Enrolled - 418 - LRB104 18483 SSS 31925 b
1 30, 2018 to account for:
2 (A) any differences between the actual payments issued
3 or scheduled to be issued prior to June 30, 2018 as
4 authorized in Section 5A-12.5 for the period of January 1,
5 2018 through June 30, 2018 and the estimated payments due
6 and payable in the month of October 2017 multiplied by 6 as
7 described in subparagraph (D); and
8 (B) any difference between the estimated
9 fee-for-service payments under subsection (b) of Section
10 5A-12.5 and the amount of such payments that are actually
11 scheduled to be paid.
12 The Department shall notify hospitals of any additional
13 amounts owed or reduction credits to be applied to the June
14 2018 ACA Assessment Adjustment. This is to be considered the
15 final reconciliation for the ACA Assessment Adjustment.
16 (3) Notwithstanding any other provision of this Section,
17 if for any reason the scheduled payments under subsection (b)
18 of Section 5A-12.5 are not issued in full by the final day of
19 the period authorized under subsection (b) of Section 5A-12.5,
20 funds collected from each hospital pursuant to subparagraph
21 (D) of paragraph (1) and pursuant to paragraph (2),
22 attributable to the scheduled payments authorized under
23 subsection (b) of Section 5A-12.5 that are not issued in full
24 by the final day of the period attributable to each payment
25 authorized under subsection (b) of Section 5A-12.5, shall be
26 refunded.
SB3365 Enrolled - 419 - LRB104 18483 SSS 31925 b
1 (4) The increases authorized under paragraph (2) of
2 subsection (a) and paragraph (2) of subsection (b-5) shall be
3 limited to the federally required State share of the total
4 payments authorized under Section 5A-12.5 if the sum of such
5 payments yields an annualized amount equal to or less than
6 $450,000,000, or if the adjustments authorized under
7 subsection (t) of Section 5A-12.2 are found not to be
8 actuarially sound; however, this limitation shall not apply to
9 the fee-for-service payments described in subsection (b) of
10 Section 5A-12.5.
11 (b-7)(1) As used in this Section, "Assessment Adjustment"
12 means:
13 (A) For the period of July 1, 2020 through December
14 31, 2020, the product of .3853 multiplied by the total of
15 the actual payments made under subsections (c) through (k)
16 of Section 5A-12.7 attributable to the period, less the
17 total of the assessment imposed under subsections (a) and
18 (b-5) of this Section for the period.
19 (B) For each calendar quarter beginning January 1,
20 2021 through December 31, 2022, the product of .3853
21 multiplied by the total of the actual payments made under
22 subsections (c) through (k) of Section 5A-12.7
23 attributable to the period, less the total of the
24 assessment imposed under subsections (a) and (b-5) of this
25 Section for the period.
26 (C) Beginning on January 1, 2023, and each subsequent
SB3365 Enrolled - 420 - LRB104 18483 SSS 31925 b
1 July 1 and January 1, the product of .3853 multiplied by
2 the total of the actual payments made under subsections
3 (c) through (j) and subsection (r) of Section 5A-12.7
4 attributable to the 6-month period immediately preceding
5 the period to which the adjustment applies, less the total
6 of the assessment imposed under subsections (a) and (b-5)
7 of this Section for the 6-month period immediately
8 preceding the period to which the adjustment applies.
9 (D) For the 6-month tax adjustment period beginning
10 July 1, 2026, the Assessment Adjustment defined in
11 subparagraph (C) of this paragraph (1) shall be half of
12 the amount calculated under subparagraph (C) of this
13 paragraph (1).
14 (2) The Department shall calculate and notify each
15 hospital of the total Assessment Adjustment and any additional
16 assessment owed by the hospital or refund owed to the hospital
17 on either a semi-annual or annual basis. Such notice shall be
18 issued at least 30 days prior to any period in which the
19 assessment will be adjusted. Any additional assessment owed by
20 the hospital or refund owed to the hospital shall be uniformly
21 applied to the assessment owed by the hospital in monthly
22 installments for the subsequent semi-annual period or calendar
23 year. If no assessment is owed in the subsequent year, any
24 amount owed by the hospital or refund due to the hospital,
25 shall be paid in a lump sum. If the calculation that is
26 computed under this Section could result in a decrease in the
SB3365 Enrolled - 421 - LRB104 18483 SSS 31925 b
1 Department's federal financial participation percentage for
2 payments authorized under Section 5A-12.7, then the Department
3 shall instead apply a uniform percentage reduction to the
4 payment rates outlined in subsection (r) of Section 5A-12.7
5 for all classes as defined in subsections (g) and (h) of
6 Section 5A-12.7 by an amount no more than necessary to
7 maximize federal reimbursement.
8 (3) The Department shall publish all details of the
9 Assessment Adjustment calculation performed each year on its
10 website within 30 days of completing the calculation, and also
11 submit the details of the Assessment Adjustment calculation as
12 part of the Department's annual report to the General
13 Assembly.
14 (b-8) Notwithstanding any other provision of this Article,
15 the Department shall reduce the assessments imposed on each
16 hospital under subsections (a) and (b-5) by the uniform
17 percentage necessary to reduce the total assessment imposed on
18 all hospitals by an aggregate amount of $240,000,000, with
19 such reduction being applied by June 30, 2022. The assessment
20 reduction required for each hospital under this subsection
21 shall be forever waived, forgiven, and released by the
22 Department.
23 (c) (Blank).
24 (d) Notwithstanding any of the other provisions of this
25 Section, the Department is authorized to adopt rules to reduce
26 the rate of any annual assessment imposed under this Section,
SB3365 Enrolled - 422 - LRB104 18483 SSS 31925 b
1 as authorized by Section 5-46.2 of the Illinois Administrative
2 Procedure Act.
3 (e) Notwithstanding any other provision of this Section,
4 any plan providing for an assessment on a hospital provider as
5 a permissible tax under Title XIX of the federal Social
6 Security Act and Medicaid-eligible payments to hospital
7 providers from the revenues derived from that assessment shall
8 be reviewed by the Illinois Department of Healthcare and
9 Family Services, as the Single State Medicaid Agency required
10 by federal law, to determine whether those assessments and
11 hospital provider payments meet federal Medicaid standards. If
12 the Department determines that the elements of the plan may
13 meet federal Medicaid standards and a related State Medicaid
14 Plan Amendment is prepared in a manner and form suitable for
15 submission, that State Plan Amendment shall be submitted in a
16 timely manner for review by the Centers for Medicare and
17 Medicaid Services of the United States Department of Health
18 and Human Services and subject to approval by the Centers for
19 Medicare and Medicaid Services of the United States Department
20 of Health and Human Services. No such plan shall become
21 effective without approval by the Illinois General Assembly by
22 the enactment into law of related legislation. Notwithstanding
23 any other provision of this Section, the Department is
24 authorized to adopt rules to reduce the rate of any annual
25 assessment imposed under this Section. Any such rules may be
26 adopted by the Department under Section 5-50 of the Illinois
SB3365 Enrolled - 423 - LRB104 18483 SSS 31925 b
1 Administrative Procedure Act.
2 (f) To provide for the expeditious and timely
3 implementation of the changes made to this Section by Public
4 Act 104-7 this amendatory Act of the 104th General Assembly,
5 the Department may adopt emergency rules as authorized by
6 Section 5-45 of the Illinois Administrative Procedure Act. The
7 adoption of emergency rules is deemed to be necessary for the
8 public interest, safety, and welfare.
9 (Source: P.A. 103-102, eff. 1-1-24; 104-7, eff. 6-16-25;
10 104-9, eff. 6-16-25; revised 8-5-25.)
11 (305 ILCS 5/5A-7) (from Ch. 23, par. 5A-7)
12 Sec. 5A-7. Administration; enforcement provisions.
13 (a) The Illinois Department shall establish and maintain a
14 listing of all hospital providers appearing in the licensing
15 records of the Illinois Department of Public Health, which
16 shall show each provider's name and principal place of
17 business and the name and address of each hospital operated,
18 conducted, or maintained by the provider in this State. The
19 listing shall also include the monthly assessment amounts owed
20 for each hospital and any unpaid assessment liability greater
21 than 90 days delinquent. The Illinois Department shall
22 administer and enforce this Article and collect the
23 assessments and penalty assessments imposed under this Article
24 using procedures employed in its administration of this Code
25 generally. The Illinois Department, its Director, and every
SB3365 Enrolled - 424 - LRB104 18483 SSS 31925 b
1 hospital provider subject to assessment under this Article
2 shall have the following powers, duties, and rights:
3 (1) The Illinois Department may initiate either
4 administrative or judicial proceedings, or both, to
5 enforce provisions of this Article. Administrative
6 enforcement proceedings initiated hereunder shall be
7 governed by the Illinois Department's administrative
8 rules. Judicial enforcement proceedings initiated
9 hereunder shall be governed by the rules of procedure
10 applicable in the courts of this State.
11 (2) (Blank).
12 (3) Any unpaid assessment under this Article shall
13 become a lien upon the assets of the hospital upon which it
14 was assessed. If any hospital provider, outside the usual
15 course of its business, sells or transfers the major part
16 of any one or more of (A) the real property and
17 improvements, (B) the machinery and equipment, or (C) the
18 furniture or fixtures, of any hospital that is subject to
19 the provisions of this Article, the seller or transferor
20 shall pay the Illinois Department the amount of any
21 assessment, assessment penalty, and interest (if any) due
22 from it under this Article up to the date of the sale or
23 transfer. The Illinois Department may, in its discretion,
24 foreclose on such a lien, but shall do so in a manner that
25 is consistent with Section 5e of the Retailers' Occupation
26 Tax Act. If the seller or transferor fails to pay any
SB3365 Enrolled - 425 - LRB104 18483 SSS 31925 b
1 assessment, assessment penalty, and interest (if any) due,
2 the purchaser or transferee of such asset shall be liable
3 for the amount of the assessment, penalties, and interest
4 (if any) up to the amount of the reasonable value of the
5 property acquired by the purchaser or transferee. The
6 purchaser or transferee shall continue to be liable until
7 the purchaser or transferee pays the full amount of the
8 assessment, penalties, and interest (if any) up to the
9 amount of the reasonable value of the property acquired by
10 the purchaser or transferee or until the purchaser or
11 transferee receives from the Illinois Department a
12 certificate showing that such assessment, penalty, and
13 interest have been paid or a certificate from the Illinois
14 Department showing that no assessment, penalty, or
15 interest is due from the seller or transferor under this
16 Article.
17 (4) Payments under this Article are not subject to the
18 Illinois Prompt Payment Act. Credits or refunds shall not
19 bear interest.
20 (b) In addition to any other remedy provided for and
21 without sending a notice of assessment liability, the Illinois
22 Department shall collect an unpaid assessment by withholding,
23 as payment of the assessment, reimbursements or other amounts
24 otherwise payable by the Illinois Department to the hospital
25 provider, including, but not limited to, payment amounts
26 otherwise payable from a managed care organization performing
SB3365 Enrolled - 426 - LRB104 18483 SSS 31925 b
1 duties under contract with the Illinois Department. To the
2 extent not prohibited by federal or State law, the Department
3 may collect an unpaid assessment by offsetting or recouping,
4 as payment of the assessment obligation, amounts otherwise
5 payable by any State agency to the hospital provider,
6 including, but not limited to, State grants and grant
7 appropriations.
8 (1) The requirements of this subsection may be waived
9 in instances when a disaster proclamation has been
10 declared by the Governor. In such circumstances, a
11 hospital must demonstrate temporary financial distress and
12 establish an agreement with the Illinois Department
13 specifying when repayment in full of all taxes owed will
14 occur.
15 (2) The requirements of this subsection may be waived
16 by the Illinois Department in instances when a hospital
17 has entered into and remains in compliance with a
18 repayment plan or a tax deferral plan. A repayment plan or
19 tax deferral plan must be entered into no later than 30
20 days after notice of an unpaid assessment payment.
21 Beginning July 1, 2026, the Illinois Department shall not
22 enter into any new tax deferral plan with a hospital. A
23 hospital may enter into a repayment plan with the
24 Department that includes terms for repayment of the total
25 amount owed over 72 months or less, repaid in equal
26 payment increments. Payments shall begin within 30 days of
SB3365 Enrolled - 427 - LRB104 18483 SSS 31925 b
1 the signed agreement date. Hospitals with existing
2 repayment agreements that were negotiated and remain in
3 effect prior to June 1, 2026 may either adhere to the terms
4 of their existing agreements or, alternatively, seek to
5 amend the existing agreement's repayment period to 72
6 months or less from the date the new agreement is entered
7 into. Renegotiated repayment plans shall include equal
8 payment increments for the total amount owed over the
9 period of the renegotiated agreement. Such renegotiated
10 repayment agreements may only include amendments to (a)
11 the length of the repayment period and (b) the payment
12 increments, provided that the total amount to be repaid
13 does not change from what remained unpaid under the
14 original repayment agreement and any additional amounts
15 owed. An existing repayment or tax deferral agreement
16 cannot be amended more than once unless otherwise agreed
17 upon by the Department. No repayment plan may exceed a
18 period of 36 months. No tax deferral plan may exceed a
19 period of 6 months, and repayment after the end of a tax
20 deferral plan shall not exceed 36 months. Failure to
21 remain in compliance with a repayment plan or tax deferral
22 plan shall cause immediate termination of such plan unless
23 there is prior written consent from the Illinois
24 Department for a period of non-compliance.
25 (3) Beginning September 1, 2025, the Illinois
26 Department shall immediately collect all overdue unpaid
SB3365 Enrolled - 428 - LRB104 18483 SSS 31925 b
1 assessments and penalties through the collection methods
2 authorized under this Section, unless a repayment plan or
3 tax deferral plan has already been agreed to by September
4 1, 2025.
5 (4) For any unpaid assessments and penalties that are
6 overdue as of the effective date of this amendatory Act of
7 the 104th General Assembly of House Bill 2771 of the 104th
8 General Assembly, upon receipt of payment the Department
9 may, at its discretion, transfer funds from the Hospital
10 Provider Fund to the Healthcare Provider Relief Fund,
11 provided that, at the time of each transfer, there are no
12 outstanding assessment-related payments owed to hospitals
13 that cannot be paid from resources remaining in the
14 Hospital Provider Fund after the transfer.
15 (c) To provide for the expeditious and timely
16 implementation of the changes made to this Section by this
17 amendatory Act of the 104th General Assembly, the Department
18 may adopt emergency rules as authorized by Section 5-45 of the
19 Illinois Administrative Procedure Act. The adoption of
20 emergency rules is deemed to be necessary for the public
21 interest, safety, and welfare.
22 (Source: P.A. 104-2, eff. 6-16-25; 104-7, eff. 6-16-25.)
23 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
24 Sec. 12-4.25. Medical assistance program; vendor
25 participation.
SB3365 Enrolled - 429 - LRB104 18483 SSS 31925 b
1 (A) The Illinois Department may deny, suspend, or
2 terminate the eligibility of any person, firm, corporation,
3 association, agency, institution or other legal entity to
4 participate as a vendor of goods or services to recipients
5 under the medical assistance program under Article V, or may
6 exclude any such person or entity from participation as such a
7 vendor, and may deny, suspend, or recover payments, if after
8 reasonable notice and opportunity for a hearing the Illinois
9 Department finds:
10 (a) Such vendor is not complying with the Department's
11 policy or rules and regulations, or with the terms and
12 conditions prescribed by the Illinois Department in its
13 vendor agreement, which document shall be developed by the
14 Department as a result of negotiations with each vendor
15 category, including physicians, hospitals, long term care
16 facilities, pharmacists, optometrists, podiatric
17 physicians, and dentists setting forth the terms and
18 conditions applicable to the participation of each vendor
19 group in the program; or
20 (b) Such vendor has failed to keep or make available
21 for inspection, audit or copying, after receiving a
22 written request from the Illinois Department, such records
23 regarding payments claimed for providing services. This
24 section does not require vendors to make available patient
25 records of patients for whom services are not reimbursed
26 under this Code; or
SB3365 Enrolled - 430 - LRB104 18483 SSS 31925 b
1 (c) Such vendor has failed to furnish any information
2 requested by the Department regarding payments for
3 providing goods or services; or
4 (d) Such vendor has knowingly made, or caused to be
5 made, any false statement or representation of a material
6 fact in connection with the administration of the medical
7 assistance program; or
8 (e) Such vendor has furnished goods or services to a
9 recipient which are (1) in excess of need, (2) harmful, or
10 (3) of grossly inferior quality, all of such
11 determinations to be based upon competent medical judgment
12 and evaluations; or
13 (f) The vendor; a person with management
14 responsibility for a vendor; an officer or person owning,
15 either directly or indirectly, 5% or more of the shares of
16 stock or other evidences of ownership in a corporate
17 vendor; an owner of a sole proprietorship which is a
18 vendor; or a partner in a partnership which is a vendor,
19 either:
20 (1) was previously terminated, suspended, or
21 excluded from participation in the Illinois medical
22 assistance program, or was terminated, suspended, or
23 excluded from participation in another state or
24 federal medical assistance or health care program; or
25 (2) was a person with management responsibility
26 for a vendor previously terminated, suspended, or
SB3365 Enrolled - 431 - LRB104 18483 SSS 31925 b
1 excluded from participation in the Illinois medical
2 assistance program, or terminated, suspended, or
3 excluded from participation in another state or
4 federal medical assistance or health care program
5 during the time of conduct which was the basis for that
6 vendor's termination, suspension, or exclusion; or
7 (3) was an officer, or person owning, either
8 directly or indirectly, 5% or more of the shares of
9 stock or other evidences of ownership in a corporate
10 or limited liability company vendor previously
11 terminated, suspended, or excluded from participation
12 in the Illinois medical assistance program, or
13 terminated, suspended, or excluded from participation
14 in a state or federal medical assistance or health
15 care program during the time of conduct which was the
16 basis for that vendor's termination, suspension, or
17 exclusion; or
18 (4) was an owner of a sole proprietorship or
19 partner of a partnership previously terminated,
20 suspended, or excluded from participation in the
21 Illinois medical assistance program, or terminated,
22 suspended, or excluded from participation in a state
23 or federal medical assistance or health care program
24 during the time of conduct which was the basis for that
25 vendor's termination, suspension, or exclusion; or
26 (f-1) Such vendor has a delinquent debt owed to the
SB3365 Enrolled - 432 - LRB104 18483 SSS 31925 b
1 Illinois Department; or
2 (g) The vendor; a person with management
3 responsibility for a vendor; an officer or person owning,
4 either directly or indirectly, 5% or more of the shares of
5 stock or other evidences of ownership in a corporate or
6 limited liability company vendor; an owner of a sole
7 proprietorship which is a vendor; or a partner in a
8 partnership which is a vendor, either:
9 (1) has engaged in practices prohibited by
10 applicable federal or State law or regulation; or
11 (2) was a person with management responsibility
12 for a vendor at the time that such vendor engaged in
13 practices prohibited by applicable federal or State
14 law or regulation; or
15 (3) was an officer, or person owning, either
16 directly or indirectly, 5% or more of the shares of
17 stock or other evidences of ownership in a vendor at
18 the time such vendor engaged in practices prohibited
19 by applicable federal or State law or regulation; or
20 (4) was an owner of a sole proprietorship or
21 partner of a partnership which was a vendor at the time
22 such vendor engaged in practices prohibited by
23 applicable federal or State law or regulation; or
24 (h) The direct or indirect ownership of the vendor
25 (including the ownership of a vendor that is a sole
26 proprietorship, a partner's interest in a vendor that is a
SB3365 Enrolled - 433 - LRB104 18483 SSS 31925 b
1 partnership, or ownership of 5% or more of the shares of
2 stock or other evidences of ownership in a corporate
3 vendor) has been transferred by an individual who is
4 terminated, suspended, or excluded or barred from
5 participating as a vendor to the individual's spouse,
6 child, brother, sister, parent, grandparent, grandchild,
7 uncle, aunt, niece, nephew, cousin, or relative by
8 marriage.
9 (A-5) The Illinois Department may deny, suspend, or
10 terminate the eligibility of any person, firm, corporation,
11 association, agency, institution, or other legal entity to
12 participate as a vendor of goods or services to recipients
13 under the medical assistance program under Article V, or may
14 exclude any such person or entity from participation as such a
15 vendor, if, after reasonable notice and opportunity for a
16 hearing, the Illinois Department finds that the vendor; a
17 person with management responsibility for a vendor; an officer
18 or person owning, either directly or indirectly, 5% or more of
19 the shares of stock or other evidences of ownership in a
20 corporate vendor; an owner of a sole proprietorship that is a
21 vendor; or a partner in a partnership that is a vendor has been
22 convicted of an offense based on fraud or willful
23 misrepresentation related to any of the following:
24 (1) The medical assistance program under Article V of
25 this Code.
26 (2) A medical assistance or health care program in
SB3365 Enrolled - 434 - LRB104 18483 SSS 31925 b
1 another state.
2 (3) The Medicare program under Title XVIII of the
3 Social Security Act.
4 (4) The provision of health care services.
5 (5) A violation of this Code, as provided in Article
6 VIIIA, or another state or federal medical assistance
7 program or health care program.
8 (A-10) The Illinois Department may deny, suspend, or
9 terminate the eligibility of any person, firm, corporation,
10 association, agency, institution, or other legal entity to
11 participate as a vendor of goods or services to recipients
12 under the medical assistance program under Article V, or may
13 exclude any such person or entity from participation as such a
14 vendor, if, after reasonable notice and opportunity for a
15 hearing, the Illinois Department finds that (i) the vendor,
16 (ii) a person with management responsibility for a vendor,
17 (iii) an officer or person owning, either directly or
18 indirectly, 5% or more of the shares of stock or other
19 evidences of ownership in a corporate vendor, (iv) an owner of
20 a sole proprietorship that is a vendor, or (v) a partner in a
21 partnership that is a vendor has been convicted of an offense
22 related to any of the following:
23 (1) Murder.
24 (2) A Class X felony under the Criminal Code of 1961 or
25 the Criminal Code of 2012.
26 (3) Sexual misconduct that may subject recipients to
SB3365 Enrolled - 435 - LRB104 18483 SSS 31925 b
1 an undue risk of harm.
2 (4) A criminal offense that may subject recipients to
3 an undue risk of harm.
4 (5) A crime of fraud or dishonesty.
5 (6) A crime involving a controlled substance.
6 (7) A misdemeanor relating to fraud, theft,
7 embezzlement, breach of fiduciary responsibility, or other
8 financial misconduct related to a health care program.
9 (A-15) The Illinois Department may deny the eligibility of
10 any person, firm, corporation, association, agency,
11 institution, or other legal entity to participate as a vendor
12 of goods or services to recipients under the medical
13 assistance program under Article V if, after reasonable notice
14 and opportunity for a hearing, the Illinois Department finds:
15 (1) The applicant or any person with management
16 responsibility for the applicant; an officer or member of
17 the board of directors of an applicant; an entity owning
18 (directly or indirectly) 5% or more of the shares of stock
19 or other evidences of ownership in a corporate vendor
20 applicant; an owner of a sole proprietorship applicant; a
21 partner in a partnership applicant; or a technical or
22 other advisor to an applicant has a debt owed to the
23 Illinois Department, and no payment arrangements
24 acceptable to the Illinois Department have been made by
25 the applicant.
26 (2) The applicant or any person with management
SB3365 Enrolled - 436 - LRB104 18483 SSS 31925 b
1 responsibility for the applicant; an officer or member of
2 the board of directors of an applicant; an entity owning
3 (directly or indirectly) 5% or more of the shares of stock
4 or other evidences of ownership in a corporate vendor
5 applicant; an owner of a sole proprietorship applicant; a
6 partner in a partnership vendor applicant; or a technical
7 or other advisor to an applicant was (i) a person with
8 management responsibility, (ii) an officer or member of
9 the board of directors of an applicant, (iii) an entity
10 owning (directly or indirectly) 5% or more of the shares
11 of stock or other evidences of ownership in a corporate
12 vendor, (iv) an owner of a sole proprietorship, (v) a
13 partner in a partnership vendor, (vi) a technical or other
14 advisor to a vendor, during a period of time where the
15 conduct of that vendor resulted in a debt owed to the
16 Illinois Department, and no payment arrangements
17 acceptable to the Illinois Department have been made by
18 that vendor.
19 (3) There is a credible allegation of the use,
20 transfer, or lease of assets of any kind to an applicant
21 from a current or prior vendor who has a debt owed to the
22 Illinois Department, no payment arrangements acceptable to
23 the Illinois Department have been made by that vendor or
24 the vendor's alternate payee, and the applicant knows or
25 should have known of such debt.
26 (4) There is a credible allegation of a transfer of
SB3365 Enrolled - 437 - LRB104 18483 SSS 31925 b
1 management responsibilities, or direct or indirect
2 ownership, to an applicant from a current or prior vendor
3 who has a debt owed to the Illinois Department, and no
4 payment arrangements acceptable to the Illinois Department
5 have been made by that vendor or the vendor's alternate
6 payee, and the applicant knows or should have known of
7 such debt.
8 (5) There is a credible allegation of the use,
9 transfer, or lease of assets of any kind to an applicant
10 who is a spouse, child, brother, sister, parent,
11 grandparent, grandchild, uncle, aunt, niece, relative by
12 marriage, nephew, cousin, or relative of a current or
13 prior vendor who has a debt owed to the Illinois
14 Department and no payment arrangements acceptable to the
15 Illinois Department have been made.
16 (6) There is a credible allegation that the
17 applicant's previous affiliations with a provider of
18 medical services that has an uncollected debt, a provider
19 that has been or is subject to a payment suspension under a
20 federal health care program, or a provider that has been
21 previously excluded from participation in the medical
22 assistance program, poses a risk of fraud, waste, or abuse
23 to the Illinois Department.
24 As used in this subsection, "credible allegation" is
25 defined to include an allegation from any source, including,
26 but not limited to, fraud hotline complaints, claims data
SB3365 Enrolled - 438 - LRB104 18483 SSS 31925 b
1 mining, patterns identified through provider audits, civil
2 actions filed under the Illinois False Claims Act, and law
3 enforcement investigations. An allegation is considered to be
4 credible when it has indicia of reliability.
5 (B) The Illinois Department shall deny, suspend or
6 terminate the eligibility of any person, firm, corporation,
7 association, agency, institution or other legal entity to
8 participate as a vendor of goods or services to recipients
9 under the medical assistance program under Article V, or may
10 exclude any such person or entity from participation as such a
11 vendor:
12 (1) immediately, if such vendor is not properly
13 licensed, certified, or authorized;
14 (2) within 30 days of the date when such vendor's
15 professional license, certification or other authorization
16 has been refused renewal, restricted, revoked, suspended,
17 or otherwise terminated; or
18 (3) if such vendor has been convicted of a violation
19 of this Code, as provided in Article VIIIA.
20 (C) Upon termination, suspension, or exclusion of a vendor
21 of goods or services from participation in the medical
22 assistance program authorized by this Article, a person with
23 management responsibility for such vendor during the time of
24 any conduct which served as the basis for that vendor's
25 termination, suspension, or exclusion is barred from
26 participation in the medical assistance program.
SB3365 Enrolled - 439 - LRB104 18483 SSS 31925 b
1 Upon termination, suspension, or exclusion of a corporate
2 vendor, the officers and persons owning, directly or
3 indirectly, 5% or more of the shares of stock or other
4 evidences of ownership in the vendor during the time of any
5 conduct which served as the basis for that vendor's
6 termination, suspension, or exclusion are barred from
7 participation in the medical assistance program. A person who
8 owns, directly or indirectly, 5% or more of the shares of stock
9 or other evidences of ownership in a terminated, suspended, or
10 excluded vendor may not transfer his or her ownership interest
11 in that vendor to his or her spouse, child, brother, sister,
12 parent, grandparent, grandchild, uncle, aunt, niece, nephew,
13 cousin, or relative by marriage.
14 Upon termination, suspension, or exclusion of a sole
15 proprietorship or partnership, the owner or partners during
16 the time of any conduct which served as the basis for that
17 vendor's termination, suspension, or exclusion are barred from
18 participation in the medical assistance program. The owner of
19 a terminated, suspended, or excluded vendor that is a sole
20 proprietorship, and a partner in a terminated, suspended, or
21 excluded vendor that is a partnership, may not transfer his or
22 her ownership or partnership interest in that vendor to his or
23 her spouse, child, brother, sister, parent, grandparent,
24 grandchild, uncle, aunt, niece, nephew, cousin, or relative by
25 marriage.
26 A person who owns, directly or indirectly, 5% or more of
SB3365 Enrolled - 440 - LRB104 18483 SSS 31925 b
1 the shares of stock or other evidences of ownership in a
2 corporate or limited liability company vendor who owes a debt
3 to the Department, if that vendor has not made payment
4 arrangements acceptable to the Department, shall not transfer
5 his or her ownership interest in that vendor, or vendor assets
6 of any kind, to his or her spouse, child, brother, sister,
7 parent, grandparent, grandchild, uncle, aunt, niece, nephew,
8 cousin, or relative by marriage.
9 Rules adopted by the Illinois Department to implement
10 these provisions shall specifically include a definition of
11 the term "management responsibility" as used in this Section.
12 Such definition shall include, but not be limited to, typical
13 job titles, and duties and descriptions which will be
14 considered as within the definition of individuals with
15 management responsibility for a provider.
16 A vendor or a prior vendor who has been terminated,
17 excluded, or suspended from the medical assistance program, or
18 from another state or federal medical assistance or health
19 care program, and any individual currently or previously
20 barred from the medical assistance program, or from another
21 state or federal medical assistance or health care program, as
22 a result of being an officer or a person owning, directly or
23 indirectly, 5% or more of the shares of stock or other
24 evidences of ownership in a corporate or limited liability
25 company vendor during the time of any conduct which served as
26 the basis for that vendor's termination, suspension, or
SB3365 Enrolled - 441 - LRB104 18483 SSS 31925 b
1 exclusion, may be required to post a surety bond as part of a
2 condition of enrollment or participation in the medical
3 assistance program. The Illinois Department shall establish,
4 by rule, the criteria and requirements for determining when a
5 surety bond must be posted and the value of the bond.
6 A vendor or a prior vendor who has a debt owed to the
7 Illinois Department and any individual currently or previously
8 barred from the medical assistance program, or from another
9 state or federal medical assistance or health care program, as
10 a result of being an officer or a person owning, directly or
11 indirectly, 5% or more of the shares of stock or other
12 evidences of ownership in that corporate or limited liability
13 company vendor during the time of any conduct which served as
14 the basis for the debt, may be required to post a surety bond
15 as part of a condition of enrollment or participation in the
16 medical assistance program. The Illinois Department shall
17 establish, by rule, the criteria and requirements for
18 determining when a surety bond must be posted and the value of
19 the bond.
20 (D) If a vendor has been suspended from the medical
21 assistance program under Article V of the Code, the Director
22 may require that such vendor correct any deficiencies which
23 served as the basis for the suspension. The Director shall
24 specify in the suspension order a specific period of time,
25 which shall not exceed one year from the date of the order,
26 during which a suspended vendor shall not be eligible to
SB3365 Enrolled - 442 - LRB104 18483 SSS 31925 b
1 participate. At the conclusion of the period of suspension the
2 Director shall reinstate such vendor, unless he finds that
3 such vendor has not corrected deficiencies upon which the
4 suspension was based.
5 If a vendor has been terminated, suspended, or excluded
6 from the medical assistance program under Article V, such
7 vendor shall be barred from participation for at least one
8 year, except that if a vendor has been terminated, suspended,
9 or excluded based on a conviction of a violation of Article
10 VIIIA or a conviction of a felony based on fraud or a willful
11 misrepresentation related to (i) the medical assistance
12 program under Article V, (ii) a federal or another state's
13 medical assistance or health care program, or (iii) the
14 provision of health care services, then the vendor shall be
15 barred from participation for 5 years or for the length of the
16 vendor's sentence for that conviction, whichever is longer. At
17 the end of one year a vendor who has been terminated,
18 suspended, or excluded may apply for reinstatement to the
19 program. Upon proper application to be reinstated such vendor
20 may be deemed eligible by the Director providing that such
21 vendor meets the requirements for eligibility under this Code.
22 If such vendor is deemed not eligible for reinstatement, he
23 shall be barred from again applying for reinstatement for one
24 year from the date his application for reinstatement is
25 denied.
26 A vendor whose termination, suspension, or exclusion from
SB3365 Enrolled - 443 - LRB104 18483 SSS 31925 b
1 participation in the Illinois medical assistance program under
2 Article V was based solely on an action by a governmental
3 entity other than the Illinois Department may, upon
4 reinstatement by that governmental entity or upon reversal of
5 the termination, suspension, or exclusion, apply for
6 rescission of the termination, suspension, or exclusion from
7 participation in the Illinois medical assistance program. Upon
8 proper application for rescission, the vendor may be deemed
9 eligible by the Director if the vendor meets the requirements
10 for eligibility under this Code.
11 If a vendor has been terminated, suspended, or excluded
12 and reinstated to the medical assistance program under Article
13 V and the vendor is terminated, suspended, or excluded a
14 second or subsequent time from the medical assistance program,
15 the vendor shall be barred from participation for at least 2
16 years, except that if a vendor has been terminated, suspended,
17 or excluded a second time based on a conviction of a violation
18 of Article VIIIA or a conviction of a felony based on fraud or
19 a willful misrepresentation related to (i) the medical
20 assistance program under Article V, (ii) a federal or another
21 state's medical assistance or health care program, or (iii)
22 the provision of health care services, then the vendor shall
23 be barred from participation for life. At the end of 2 years, a
24 vendor who has been terminated, suspended, or excluded may
25 apply for reinstatement to the program. Upon application to be
26 reinstated, the vendor may be deemed eligible if the vendor
SB3365 Enrolled - 444 - LRB104 18483 SSS 31925 b
1 meets the requirements for eligibility under this Code. If the
2 vendor is deemed not eligible for reinstatement, the vendor
3 shall be barred from again applying for reinstatement for 2
4 years from the date the vendor's application for reinstatement
5 is denied.
6 (E) The Illinois Department may recover money improperly
7 or erroneously paid, or overpayments, either by setoff,
8 crediting against future billings or by requiring direct
9 repayment to the Illinois Department. The Illinois Department
10 may suspend or deny payment, in whole or in part, if such
11 payment would be improper or erroneous or would otherwise
12 result in overpayment.
13 (1) Payments may be suspended, denied, or recovered
14 from a vendor or alternate payee: (i) for services
15 rendered in violation of the Illinois Department's
16 provider notices, statutes, rules, and regulations; (ii)
17 for services rendered in violation of the terms and
18 conditions prescribed by the Illinois Department in its
19 vendor agreement; (iii) for any vendor who fails to grant
20 the Office of Inspector General timely access to full and
21 complete records, including, but not limited to, records
22 relating to recipients under the medical assistance
23 program for the most recent 6 years, in accordance with
24 Section 140.28 of Title 89 of the Illinois Administrative
25 Code, and other information for the purpose of audits,
26 investigations, or other program integrity functions,
SB3365 Enrolled - 445 - LRB104 18483 SSS 31925 b
1 after reasonable written request by the Inspector General;
2 this subsection (E) does not require vendors to make
3 available the medical records of patients for whom
4 services are not reimbursed under this Code or to provide
5 access to medical records more than 6 years old; (iv) when
6 the vendor has knowingly made, or caused to be made, any
7 false statement or representation of a material fact in
8 connection with the administration of the medical
9 assistance program; or (v) when the vendor previously
10 rendered services while terminated, suspended, or excluded
11 from participation in the medical assistance program or
12 while terminated or excluded from participation in another
13 state or federal medical assistance or health care
14 program.
15 (2) Notwithstanding any other provision of law, if a
16 vendor has the same taxpayer identification number
17 (assigned under Section 6109 of the Internal Revenue Code
18 of 1986) as is assigned to a vendor with past-due
19 financial obligations to the Illinois Department, the
20 Illinois Department may make any necessary adjustments to
21 payments to that vendor in order to satisfy any past-due
22 obligations, regardless of whether the vendor is assigned
23 a different billing number under the medical assistance
24 program.
25 (E-5) Civil monetary penalties.
26 (1) As used in this subsection (E-5):
SB3365 Enrolled - 446 - LRB104 18483 SSS 31925 b
1 (a) "Knowingly" means that a person, with respect
2 to information: (i) has actual knowledge of the
3 information; (ii) acts in deliberate ignorance of the
4 truth or falsity of the information; or (iii) acts in
5 reckless disregard of the truth or falsity of the
6 information. No proof of specific intent to defraud is
7 required.
8 (b) "Overpayment" means any funds that a person
9 receives or retains from the medical assistance
10 program to which the person, after applicable
11 reconciliation, is not entitled under this Code.
12 (c) "Remuneration" means the offer or transfer of
13 items or services for free or for other than fair
14 market value by a person; however, remuneration does
15 not include items or services of a nominal value of no
16 more than $10 per item or service, or $50 in the
17 aggregate on an annual basis, or any other offer or
18 transfer of items or services as determined by the
19 Department.
20 (d) "Should know" means that a person, with
21 respect to information: (i) acts in deliberate
22 ignorance of the truth or falsity of the information;
23 or (ii) acts in reckless disregard of the truth or
24 falsity of the information. No proof of specific
25 intent to defraud is required.
26 (2) Any person (including a vendor, provider,
SB3365 Enrolled - 447 - LRB104 18483 SSS 31925 b
1 organization, agency, or other entity, or an alternate
2 payee thereof, but excluding a recipient) who:
3 (a) knowingly presents or causes to be presented
4 to an officer, employee, or agent of the State, a claim
5 that the Department determines:
6 (i) is for a medical or other item or service
7 that the person knows or should know was not
8 provided as claimed, including any person who
9 engages in a pattern or practice of presenting or
10 causing to be presented a claim for an item or
11 service that is based on a code that the person
12 knows or should know will result in a greater
13 payment to the person than the code the person
14 knows or should know is applicable to the item or
15 service actually provided;
16 (ii) is for a medical or other item or service
17 and the person knows or should know that the claim
18 is false or fraudulent;
19 (iii) is presented for a vendor physician's
20 service, or an item or service incident to a
21 vendor physician's service, by a person who knows
22 or should know that the individual who furnished,
23 or supervised the furnishing of, the service:
24 (AA) was not licensed as a physician;
25 (BB) was licensed as a physician but such
26 license had been obtained through a
SB3365 Enrolled - 448 - LRB104 18483 SSS 31925 b
1 misrepresentation of material fact (including
2 cheating on an examination required for
3 licensing); or
4 (CC) represented to the patient at the
5 time the service was furnished that the
6 physician was certified in a medical specialty
7 by a medical specialty board, when the
8 individual was not so certified;
9 (iv) is for a medical or other item or service
10 furnished during a period in which the person was
11 excluded from the medical assistance program or a
12 federal or state health care program under which
13 the claim was made pursuant to applicable law; or
14 (v) is for a pattern of medical or other items
15 or services that a person knows or should know are
16 not medically necessary;
17 (b) knowingly presents or causes to be presented
18 to any person a request for payment which is in
19 violation of the conditions for receipt of vendor
20 payments under the medical assistance program under
21 Section 11-13 of this Code;
22 (c) knowingly gives or causes to be given to any
23 person, with respect to medical assistance program
24 coverage of inpatient hospital services, information
25 that he or she knows or should know is false or
26 misleading, and that could reasonably be expected to
SB3365 Enrolled - 449 - LRB104 18483 SSS 31925 b
1 influence the decision when to discharge such person
2 or other individual from the hospital;
3 (d) in the case of a person who is not an
4 organization, agency, or other entity, is excluded
5 from participating in the medical assistance program
6 or a federal or state health care program and who, at
7 the time of a violation of this subsection (E-5):
8 (i) retains a direct or indirect ownership or
9 control interest in an entity that is
10 participating in the medical assistance program or
11 a federal or state health care program, and who
12 knows or should know of the action constituting
13 the basis for the exclusion; or
14 (ii) is an officer or managing employee of
15 such an entity;
16 (e) offers or transfers remuneration to any
17 individual eligible for benefits under the medical
18 assistance program that such person knows or should
19 know is likely to influence such individual to order
20 or receive from a particular vendor, provider,
21 practitioner, or supplier any item or service for
22 which payment may be made, in whole or in part, under
23 the medical assistance program;
24 (f) arranges or contracts (by employment or
25 otherwise) with an individual or entity that the
26 person knows or should know is excluded from
SB3365 Enrolled - 450 - LRB104 18483 SSS 31925 b
1 participation in the medical assistance program or a
2 federal or state health care program, for the
3 provision of items or services for which payment may
4 be made under such a program;
5 (g) commits an act described in subsection (b) or
6 (c) of Section 8A-3;
7 (h) knowingly makes, uses, or causes to be made or
8 used, a false record or statement material to a false
9 or fraudulent claim for payment for items and services
10 furnished under the medical assistance program;
11 (i) fails to grant timely access, upon reasonable
12 request (as defined by the Department by rule), to the
13 Inspector General, for the purpose of audits,
14 investigations, evaluations, or other statutory
15 functions of the Inspector General of the Department;
16 (j) orders or prescribes a medical or other item
17 or service during a period in which the person was
18 excluded from the medical assistance program or a
19 federal or state health care program, in the case
20 where the person knows or should know that a claim for
21 such medical or other item or service will be made
22 under such a program;
23 (k) knowingly makes or causes to be made any false
24 statement, omission, or misrepresentation of a
25 material fact in any application, bid, or contract to
26 participate or enroll as a vendor or provider of
SB3365 Enrolled - 451 - LRB104 18483 SSS 31925 b
1 services or a supplier under the medical assistance
2 program;
3 (l) knows of an overpayment and does not report
4 and return the overpayment to the Department in
5 accordance with paragraph (6);
6 shall be subject, in addition to any other penalties that
7 may be prescribed by law, to a civil money penalty of not
8 more than $10,000 for each item or service (or, in cases
9 under subparagraph (c), $15,000 for each individual with
10 respect to whom false or misleading information was given;
11 in cases under subparagraph (d), $10,000 for each day the
12 prohibited relationship occurs; in cases under
13 subparagraph (g), $50,000 for each such act; in cases
14 under subparagraph (h), $50,000 for each false record or
15 statement; in cases under subparagraph (i), $15,000 for
16 each day of the failure described in such subparagraph; or
17 in cases under subparagraph (k), $50,000 for each false
18 statement, omission, or misrepresentation of a material
19 fact). In addition, such a person shall be subject to an
20 assessment of not more than 3 times the amount claimed for
21 each such item or service in lieu of damages sustained by
22 the State because of such claim (or, in cases under
23 subparagraph (g), damages of not more than 3 times the
24 total amount of remuneration offered, paid, solicited, or
25 received, without regard to whether a portion of such
26 remuneration was offered, paid, solicited, or received for
SB3365 Enrolled - 452 - LRB104 18483 SSS 31925 b
1 a lawful purpose; or in cases under subparagraph (k), an
2 assessment of not more than 3 times the total amount
3 claimed for each item or service for which payment was
4 made based upon the application, bid, or contract
5 containing the false statement, omission, or
6 misrepresentation of a material fact).
7 (3) In addition, the Director or his or her designee
8 may make a determination in the same proceeding to
9 exclude, terminate, suspend, or bar the person from
10 participation in the medical assistance program.
11 (4) The Illinois Department may seek the civil
12 monetary penalties and exclusion, termination, suspension,
13 or barment identified in this subsection (E-5). Prior to
14 the imposition of any penalties or sanctions, the affected
15 person shall be afforded an opportunity for a hearing
16 after reasonable notice. The Department shall establish
17 hearing procedures by rule.
18 (5) Any final order, decision, or other determination
19 made, issued, or executed by the Director under the
20 provisions of this subsection (E-5), whereby a person is
21 aggrieved, shall be subject to review in accordance with
22 the provisions of the Administrative Review Law, and the
23 rules adopted pursuant thereto, which shall apply to and
24 govern all proceedings for the judicial review of final
25 administrative decisions of the Director.
26 (6)(a) If a person has received an overpayment, the
SB3365 Enrolled - 453 - LRB104 18483 SSS 31925 b
1 person shall:
2 (i) report and return the overpayment to the
3 Department at the correct address; and
4 (ii) notify the Department in writing of the
5 reason for the overpayment.
6 (b) An overpayment must be reported and returned under
7 subparagraph (a) by the later of:
8 (i) the date which is 60 days after the date on
9 which the overpayment was identified; or
10 (ii) the date any corresponding cost report is
11 due, if applicable.
12 (E-10) A vendor who disputes an overpayment identified as
13 part of a Department audit shall utilize the Department's
14 self-referral disclosure protocol as set forth under this Code
15 to identify, investigate, and return to the Department any
16 undisputed audit overpayment amount. Unless the disputed
17 overpayment amount is subject to a fraud payment suspension,
18 or involves a termination sanction, the Department shall defer
19 the recovery of the disputed overpayment amount up to one year
20 after the date of the Department's final audit determination,
21 or earlier, or as required by State or federal law. If the
22 administrative hearing extends beyond one year, and such delay
23 was not caused by the request of the vendor, then the
24 Department shall not recover the disputed overpayment amount
25 until the date of the final administrative decision. If a
26 final administrative decision establishes that the disputed
SB3365 Enrolled - 454 - LRB104 18483 SSS 31925 b
1 overpayment amount is owed to the Department, then the amount
2 shall be immediately due to the Department. The Department
3 shall be entitled to recover interest from the vendor on the
4 overpayment amount from the date of the overpayment through
5 the date the vendor returns the overpayment to the Department
6 at a rate not to exceed the Wall Street Journal Prime Rate, as
7 published from time to time, but not to exceed 5%. Any interest
8 billed by the Department shall be due immediately upon receipt
9 of the Department's billing statement.
10 (F) The Illinois Department may withhold payments to any
11 vendor or alternate payee prior to or during the pendency of
12 any audit or proceeding under this Section, and through the
13 pendency of any administrative appeal or administrative review
14 by any court proceeding. The Illinois Department shall state
15 by rule with as much specificity as practicable the conditions
16 under which payments will not be withheld under this Section.
17 Payments may be denied for bills submitted with service dates
18 occurring during the pendency of a proceeding, after a final
19 decision has been rendered, or after the conclusion of any
20 administrative appeal, where the final administrative decision
21 is to terminate, exclude, or suspend eligibility to
22 participate in the medical assistance program. The Illinois
23 Department shall state by rule with as much specificity as
24 practicable the conditions under which payments will not be
25 denied for such bills. The Illinois Department shall state by
26 rule a process and criteria by which a vendor or alternate
SB3365 Enrolled - 455 - LRB104 18483 SSS 31925 b
1 payee may request full or partial release of payments withheld
2 under this subsection. The Department must complete a
3 proceeding under this Section in a timely manner.
4 Notwithstanding recovery allowed under subsection (E) or
5 this subsection (F), the Illinois Department may withhold
6 payments to any vendor or alternate payee who is not properly
7 licensed, certified, or in compliance with State or federal
8 agency regulations. Payments may be denied for bills submitted
9 with service dates occurring during the period of time that a
10 vendor is not properly licensed, certified, or in compliance
11 with State or federal regulations. Facilities licensed under
12 the Nursing Home Care Act shall have payments denied or
13 withheld pursuant to subsection (I) of this Section.
14 (F-5) The Illinois Department may temporarily withhold
15 payments to a vendor or alternate payee if any of the following
16 individuals have been indicted or otherwise charged under a
17 law of the United States or this or any other state with an
18 offense that is based on alleged fraud or willful
19 misrepresentation on the part of the individual related to (i)
20 the medical assistance program under Article V of this Code,
21 (ii) a federal or another state's medical assistance or health
22 care program, or (iii) the provision of health care services:
23 (1) If the vendor or alternate payee is a corporation:
24 an officer of the corporation or an individual who owns,
25 either directly or indirectly, 5% or more of the shares of
26 stock or other evidence of ownership of the corporation.
SB3365 Enrolled - 456 - LRB104 18483 SSS 31925 b
1 (2) If the vendor is a sole proprietorship: the owner
2 of the sole proprietorship.
3 (3) If the vendor or alternate payee is a partnership:
4 a partner in the partnership.
5 (4) If the vendor or alternate payee is any other
6 business entity authorized by law to transact business in
7 this State: an officer of the entity or an individual who
8 owns, either directly or indirectly, 5% or more of the
9 evidences of ownership of the entity.
10 If the Illinois Department withholds payments to a vendor
11 or alternate payee under this subsection, the Department shall
12 not release those payments to the vendor or alternate payee
13 while any criminal proceeding related to the indictment or
14 charge is pending unless the Department determines that there
15 is good cause to release the payments before completion of the
16 proceeding. If the indictment or charge results in the
17 individual's conviction, the Illinois Department shall retain
18 all withheld payments, which shall be considered forfeited to
19 the Department. If the indictment or charge does not result in
20 the individual's conviction, the Illinois Department shall
21 release to the vendor or alternate payee all withheld
22 payments.
23 (F-10) If the Illinois Department establishes that the
24 vendor or alternate payee owes a debt to the Illinois
25 Department, and the vendor or alternate payee subsequently
26 fails to pay or make satisfactory payment arrangements with
SB3365 Enrolled - 457 - LRB104 18483 SSS 31925 b
1 the Illinois Department for the debt owed, the Illinois
2 Department may seek all remedies available under the law of
3 this State to recover the debt, including, but not limited to,
4 wage garnishment or the filing of claims or liens against the
5 vendor or alternate payee.
6 (F-15) Enforcement of judgment.
7 (1) Any fine, recovery amount, other sanction, or
8 costs imposed, or part of any fine, recovery amount, other
9 sanction, or cost imposed, remaining unpaid after the
10 exhaustion of or the failure to exhaust judicial review
11 procedures under the Illinois Administrative Review Law is
12 a debt due and owing the State and may be collected using
13 all remedies available under the law.
14 (2) After expiration of the period in which judicial
15 review under the Illinois Administrative Review Law may be
16 sought for a final administrative decision, unless stayed
17 by a court of competent jurisdiction, the findings,
18 decision, and order of the Director may be enforced in the
19 same manner as a judgment entered by a court of competent
20 jurisdiction.
21 (3) In any case in which any person or entity has
22 failed to comply with a judgment ordering or imposing any
23 fine or other sanction, any expenses incurred by the
24 Illinois Department to enforce the judgment, including,
25 but not limited to, attorney's fees, court costs, and
26 costs related to property demolition or foreclosure, after
SB3365 Enrolled - 458 - LRB104 18483 SSS 31925 b
1 they are fixed by a court of competent jurisdiction or the
2 Director, shall be a debt due and owing the State and may
3 be collected in accordance with applicable law. Prior to
4 any expenses being fixed by a final administrative
5 decision pursuant to this subsection (F-15), the Illinois
6 Department shall provide notice to the individual or
7 entity that states that the individual or entity shall
8 appear at a hearing before the administrative hearing
9 officer to determine whether the individual or entity has
10 failed to comply with the judgment. The notice shall set
11 the date for such a hearing, which shall not be less than 7
12 days from the date that notice is served. If notice is
13 served by mail, the 7-day period shall begin to run on the
14 date that the notice was deposited in the mail.
15 (4) Upon being recorded in the manner required by
16 Article XII of the Code of Civil Procedure or by the
17 Uniform Commercial Code, a lien shall be imposed on the
18 real estate or personal estate, or both, of the individual
19 or entity in the amount of any debt due and owing the State
20 under this Section. The lien may be enforced in the same
21 manner as a judgment of a court of competent jurisdiction.
22 A lien shall attach to all property and assets of such
23 person, firm, corporation, association, agency,
24 institution, or other legal entity until the judgment is
25 satisfied.
26 (5) The Director may set aside any judgment entered by
SB3365 Enrolled - 459 - LRB104 18483 SSS 31925 b
1 default and set a new hearing date upon a petition filed at
2 any time (i) if the petitioner's failure to appear at the
3 hearing was for good cause, or (ii) if the petitioner
4 established that the Department did not provide proper
5 service of process. If any judgment is set aside pursuant
6 to this paragraph (5), the hearing officer shall have
7 authority to enter an order extinguishing any lien which
8 has been recorded for any debt due and owing the Illinois
9 Department as a result of the vacated default judgment.
10 (G) The provisions of the Administrative Review Law, as
11 now or hereafter amended, and the rules adopted pursuant
12 thereto, shall apply to and govern all proceedings for the
13 judicial review of final administrative decisions of the
14 Illinois Department under this Section. The term
15 "administrative decision" is defined as in Section 3-101 of
16 the Code of Civil Procedure.
17 (G-5) Vendors who pose a risk of fraud, waste, abuse, or
18 harm.
19 (1) Notwithstanding any other provision in this
20 Section, the Department may terminate, suspend, or exclude
21 vendors who pose a risk of fraud, waste, abuse, or harm
22 from participation in the medical assistance program prior
23 to an evidentiary hearing but after reasonable notice and
24 opportunity to respond as established by the Department by
25 rule.
26 (2) Vendors who pose a risk of fraud, waste, abuse, or
SB3365 Enrolled - 460 - LRB104 18483 SSS 31925 b
1 harm shall submit to a fingerprint-based criminal
2 background check on current and future information
3 available in the State system and current information
4 available through the Federal Bureau of Investigation's
5 system by submitting all necessary fees and information in
6 the form and manner prescribed by the Illinois State
7 Police. The following individuals shall be subject to the
8 check:
9 (A) In the case of a vendor that is a corporation,
10 every shareholder who owns, directly or indirectly, 5%
11 or more of the outstanding shares of the corporation.
12 (B) In the case of a vendor that is a partnership,
13 every partner.
14 (C) In the case of a vendor that is a sole
15 proprietorship, the sole proprietor.
16 (D) Each officer or manager of the vendor.
17 Each such vendor shall be responsible for payment of
18 the cost of the criminal background check.
19 (3) Vendors who pose a risk of fraud, waste, abuse, or
20 harm may be required to post a surety bond. The Department
21 shall establish, by rule, the criteria and requirements
22 for determining when a surety bond must be posted and the
23 value of the bond.
24 (4) The Department, or its agents, may refuse to
25 accept requests for authorization from specific vendors
26 who pose a risk of fraud, waste, abuse, or harm, including
SB3365 Enrolled - 461 - LRB104 18483 SSS 31925 b
1 prior-approval and post-approval requests, if:
2 (A) the Department has initiated a notice of
3 termination, suspension, or exclusion of the vendor
4 from participation in the medical assistance program;
5 or
6 (B) the Department has issued notification of its
7 withholding of payments pursuant to subsection (F-5)
8 of this Section; or
9 (C) the Department has issued a notification of
10 its withholding of payments due to reliable evidence
11 of fraud or willful misrepresentation pending
12 investigation.
13 (5) As used in this subsection, the following terms
14 are defined as follows:
15 (A) "Fraud" means an intentional deception or
16 misrepresentation made by a person with the knowledge
17 that the deception could result in some unauthorized
18 benefit to himself or herself or some other person. It
19 includes any act that constitutes fraud under
20 applicable federal or State law.
21 (B) "Abuse" means provider practices that are
22 inconsistent with sound fiscal, business, or medical
23 practices and that result in an unnecessary cost to
24 the medical assistance program or in reimbursement for
25 services that are not medically necessary or that fail
26 to meet professionally recognized standards for health
SB3365 Enrolled - 462 - LRB104 18483 SSS 31925 b
1 care. It also includes recipient practices that result
2 in unnecessary cost to the medical assistance program.
3 Abuse does not include diagnostic or therapeutic
4 measures conducted primarily as a safeguard against
5 possible vendor liability.
6 (C) "Waste" means the unintentional misuse of
7 medical assistance resources, resulting in unnecessary
8 cost to the medical assistance program. Waste does not
9 include diagnostic or therapeutic measures conducted
10 primarily as a safeguard against possible vendor
11 liability.
12 (D) "Harm" means physical, mental, or monetary
13 damage to recipients or to the medical assistance
14 program.
15 (G-6) The Illinois Department, upon making a determination
16 based upon information in the possession of the Illinois
17 Department that continuation of participation in the medical
18 assistance program by a vendor would constitute an immediate
19 danger to the public, may immediately suspend such vendor's
20 participation in the medical assistance program without a
21 hearing. In instances in which the Illinois Department
22 immediately suspends the medical assistance program
23 participation of a vendor under this Section, a hearing upon
24 the vendor's participation must be convened by the Illinois
25 Department within 15 days after such suspension and completed
26 without appreciable delay. Such hearing shall be held to
SB3365 Enrolled - 463 - LRB104 18483 SSS 31925 b
1 determine whether to recommend to the Director that the
2 vendor's medical assistance program participation be denied,
3 terminated, suspended, placed on provisional status, or
4 reinstated. In the hearing, any evidence relevant to the
5 vendor constituting an immediate danger to the public may be
6 introduced against such vendor; provided, however, that the
7 vendor, or his or her counsel, shall have the opportunity to
8 discredit, impeach, and submit evidence rebutting such
9 evidence.
10 (H) Nothing contained in this Code shall in any way limit
11 or otherwise impair the authority or power of any State agency
12 responsible for licensing of vendors.
13 (I) Based on a finding of noncompliance on the part of a
14 nursing home with any requirement for certification under
15 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
16 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
17 Department may impose one or more of the following remedies
18 after notice to the facility:
19 (1) Termination of the provider agreement.
20 (2) Temporary management.
21 (3) Denial of payment for new admissions.
22 (4) Civil money penalties.
23 (5) Closure of the facility in emergency situations or
24 transfer of residents, or both.
25 (6) State monitoring.
26 (7) Denial of all payments when the U.S. Department of
SB3365 Enrolled - 464 - LRB104 18483 SSS 31925 b
1 Health and Human Services has imposed this sanction.
2 The Illinois Department shall by rule establish criteria
3 governing continued payments to a nursing facility subsequent
4 to termination of the facility's provider agreement if, in the
5 sole discretion of the Illinois Department, circumstances
6 affecting the health, safety, and welfare of the facility's
7 residents require those continued payments. The Illinois
8 Department may condition those continued payments on the
9 appointment of temporary management, sale of the facility to
10 new owners or operators, or other arrangements that the
11 Illinois Department determines best serve the needs of the
12 facility's residents.
13 Except in the case of a facility that has a right to a
14 hearing on the finding of noncompliance before an agency of
15 the federal government, a facility may request a hearing
16 before a State agency on any finding of noncompliance within
17 60 days after the notice of the intent to impose a remedy.
18 Except in the case of civil money penalties, a request for a
19 hearing shall not delay imposition of the penalty. The choice
20 of remedies is not appealable at a hearing. The level of
21 noncompliance may be challenged only in the case of a civil
22 money penalty. The Illinois Department shall provide by rule
23 for the State agency that will conduct the evidentiary
24 hearings.
25 The Illinois Department may collect interest on unpaid
26 civil money penalties.
SB3365 Enrolled - 465 - LRB104 18483 SSS 31925 b
1 The Illinois Department may adopt all rules necessary to
2 implement this subsection (I).
3 (J) The Illinois Department, by rule, may permit
4 individual practitioners to designate that Department payments
5 that may be due the practitioner be made to an alternate payee
6 or alternate payees.
7 (a) Such alternate payee or alternate payees shall be
8 required to register as an alternate payee in the Medical
9 Assistance Program with the Illinois Department.
10 (b) If a practitioner designates an alternate payee,
11 the alternate payee and practitioner shall be jointly and
12 severally liable to the Department for payments made to
13 the alternate payee. Pursuant to subsection (E) of this
14 Section, any Department action to suspend or deny payment
15 or recover money or overpayments from an alternate payee
16 shall be subject to an administrative hearing.
17 (c) Registration as an alternate payee or alternate
18 payees in the Illinois Medical Assistance Program shall be
19 conditional. At any time, the Illinois Department may deny
20 or cancel any alternate payee's registration in the
21 Illinois Medical Assistance Program without cause. Any
22 such denial or cancellation is not subject to an
23 administrative hearing.
24 (d) The Illinois Department may seek a revocation of
25 any alternate payee, and all owners, officers, and
26 individuals with management responsibility for such
SB3365 Enrolled - 466 - LRB104 18483 SSS 31925 b
1 alternate payee shall be permanently prohibited from
2 participating as an owner, an officer, or an individual
3 with management responsibility with an alternate payee in
4 the Illinois Medical Assistance Program, if after
5 reasonable notice and opportunity for a hearing the
6 Illinois Department finds that:
7 (1) the alternate payee is not complying with the
8 Department's policy or rules and regulations, or with
9 the terms and conditions prescribed by the Illinois
10 Department in its alternate payee registration
11 agreement; or
12 (2) the alternate payee has failed to keep or make
13 available for inspection, audit, or copying, after
14 receiving a written request from the Illinois
15 Department, such records regarding payments claimed as
16 an alternate payee; or
17 (3) the alternate payee has failed to furnish any
18 information requested by the Illinois Department
19 regarding payments claimed as an alternate payee; or
20 (4) the alternate payee has knowingly made, or
21 caused to be made, any false statement or
22 representation of a material fact in connection with
23 the administration of the Illinois Medical Assistance
24 Program; or
25 (5) the alternate payee, a person with management
26 responsibility for an alternate payee, an officer or
SB3365 Enrolled - 467 - LRB104 18483 SSS 31925 b
1 person owning, either directly or indirectly, 5% or
2 more of the shares of stock or other evidences of
3 ownership in a corporate alternate payee, or a partner
4 in a partnership which is an alternate payee:
5 (a) was previously terminated, suspended, or
6 excluded from participation as a vendor in the
7 Illinois Medical Assistance Program, or was
8 previously revoked as an alternate payee in the
9 Illinois Medical Assistance Program, or was
10 terminated, suspended, or excluded from
11 participation as a vendor in a medical assistance
12 program in another state that is of the same kind
13 as the program of medical assistance provided
14 under Article V of this Code; or
15 (b) was a person with management
16 responsibility for a vendor previously terminated,
17 suspended, or excluded from participation as a
18 vendor in the Illinois Medical Assistance Program,
19 or was previously revoked as an alternate payee in
20 the Illinois Medical Assistance Program, or was
21 terminated, suspended, or excluded from
22 participation as a vendor in a medical assistance
23 program in another state that is of the same kind
24 as the program of medical assistance provided
25 under Article V of this Code, during the time of
26 conduct which was the basis for that vendor's
SB3365 Enrolled - 468 - LRB104 18483 SSS 31925 b
1 termination, suspension, or exclusion or alternate
2 payee's revocation; or
3 (c) was an officer, or person owning, either
4 directly or indirectly, 5% or more of the shares
5 of stock or other evidences of ownership in a
6 corporate vendor previously terminated, suspended,
7 or excluded from participation as a vendor in the
8 Illinois Medical Assistance Program, or was
9 previously revoked as an alternate payee in the
10 Illinois Medical Assistance Program, or was
11 terminated, suspended, or excluded from
12 participation as a vendor in a medical assistance
13 program in another state that is of the same kind
14 as the program of medical assistance provided
15 under Article V of this Code, during the time of
16 conduct which was the basis for that vendor's
17 termination, suspension, or exclusion; or
18 (d) was an owner of a sole proprietorship or
19 partner in a partnership previously terminated,
20 suspended, or excluded from participation as a
21 vendor in the Illinois Medical Assistance Program,
22 or was previously revoked as an alternate payee in
23 the Illinois Medical Assistance Program, or was
24 terminated, suspended, or excluded from
25 participation as a vendor in a medical assistance
26 program in another state that is of the same kind
SB3365 Enrolled - 469 - LRB104 18483 SSS 31925 b
1 as the program of medical assistance provided
2 under Article V of this Code, during the time of
3 conduct which was the basis for that vendor's
4 termination, suspension, or exclusion or alternate
5 payee's revocation; or
6 (6) the alternate payee, a person with management
7 responsibility for an alternate payee, an officer or
8 person owning, either directly or indirectly, 5% or
9 more of the shares of stock or other evidences of
10 ownership in a corporate alternate payee, or a partner
11 in a partnership which is an alternate payee:
12 (a) has engaged in conduct prohibited by
13 applicable federal or State law or regulation
14 relating to the Illinois Medical Assistance
15 Program; or
16 (b) was a person with management
17 responsibility for a vendor or alternate payee at
18 the time that the vendor or alternate payee
19 engaged in practices prohibited by applicable
20 federal or State law or regulation relating to the
21 Illinois Medical Assistance Program; or
22 (c) was an officer, or person owning, either
23 directly or indirectly, 5% or more of the shares
24 of stock or other evidences of ownership in a
25 vendor or alternate payee at the time such vendor
26 or alternate payee engaged in practices prohibited
SB3365 Enrolled - 470 - LRB104 18483 SSS 31925 b
1 by applicable federal or State law or regulation
2 relating to the Illinois Medical Assistance
3 Program; or
4 (d) was an owner of a sole proprietorship or
5 partner in a partnership which was a vendor or
6 alternate payee at the time such vendor or
7 alternate payee engaged in practices prohibited by
8 applicable federal or State law or regulation
9 relating to the Illinois Medical Assistance
10 Program; or
11 (7) the direct or indirect ownership of the vendor
12 or alternate payee (including the ownership of a
13 vendor or alternate payee that is a partner's interest
14 in a vendor or alternate payee, or ownership of 5% or
15 more of the shares of stock or other evidences of
16 ownership in a corporate vendor or alternate payee)
17 has been transferred by an individual who is
18 terminated, suspended, or excluded or barred from
19 participating as a vendor or is prohibited or revoked
20 as an alternate payee to the individual's spouse,
21 child, brother, sister, parent, grandparent,
22 grandchild, uncle, aunt, niece, nephew, cousin, or
23 relative by marriage.
24 (K) The Illinois Department of Healthcare and Family
25 Services may withhold payments, in whole or in part, to a
26 provider or alternate payee where there is credible evidence,
SB3365 Enrolled - 471 - LRB104 18483 SSS 31925 b
1 received from State or federal law enforcement or federal
2 oversight agencies or from the results of a preliminary
3 Department audit, that the circumstances giving rise to the
4 need for a withholding of payments may involve fraud or
5 willful misrepresentation under the Illinois Medical
6 Assistance program. The Department shall by rule define what
7 constitutes "credible" evidence for purposes of this
8 subsection. The Department may withhold payments without first
9 notifying the provider or alternate payee of its intention to
10 withhold such payments. A provider or alternate payee may
11 request a reconsideration of payment withholding, and the
12 Department must grant such a request. The Department shall
13 state by rule a process and criteria by which a provider or
14 alternate payee may request full or partial release of
15 payments withheld under this subsection. This request may be
16 made at any time after the Department first withholds such
17 payments.
18 (a) The Illinois Department must send notice of its
19 withholding of program payments within 5 days of taking
20 such action. The notice must set forth the general
21 allegations as to the nature of the withholding action,
22 but need not disclose any specific information concerning
23 its ongoing investigation. The notice must do all of the
24 following:
25 (1) State that payments are being withheld in
26 accordance with this subsection.
SB3365 Enrolled - 472 - LRB104 18483 SSS 31925 b
1 (2) State that the withholding is for a temporary
2 period, as stated in paragraph (b) of this subsection,
3 and cite the circumstances under which withholding
4 will be terminated.
5 (3) Specify, when appropriate, which type or types
6 of Medicaid claims withholding is effective.
7 (4) Inform the provider or alternate payee of the
8 right to submit written evidence for reconsideration
9 of the withholding by the Illinois Department.
10 (5) Inform the provider or alternate payee that a
11 written request may be made to the Illinois Department
12 for full or partial release of withheld payments and
13 that such requests may be made at any time after the
14 Department first withholds such payments.
15 (b) All withholding-of-payment actions under this
16 subsection shall be temporary and shall not continue after
17 any of the following:
18 (1) The Illinois Department or the prosecuting
19 authorities determine that there is insufficient
20 evidence of fraud or willful misrepresentation by the
21 provider or alternate payee.
22 (2) Legal proceedings related to the provider's or
23 alternate payee's alleged fraud, willful
24 misrepresentation, violations of this Act, or
25 violations of the Illinois Department's administrative
26 rules are completed.
SB3365 Enrolled - 473 - LRB104 18483 SSS 31925 b
1 (3) The withholding of payments for a period of 3
2 years.
3 (c) The Illinois Department may adopt all rules
4 necessary to implement this subsection (K).
5 (K-5) The Illinois Department may withhold payments, in
6 whole or in part, to a provider or alternate payee upon
7 initiation of an audit, quality of care review, investigation
8 when there is a credible allegation of fraud, or the provider
9 or alternate payee demonstrating a clear failure to cooperate
10 with the Illinois Department such that the circumstances give
11 rise to the need for a withholding of payments. As used in this
12 subsection, "credible allegation" is defined to include an
13 allegation from any source, including, but not limited to,
14 fraud hotline complaints, claims data mining, patterns
15 identified through provider audits, civil actions filed under
16 the Illinois False Claims Act, and law enforcement
17 investigations. An allegation is considered to be credible
18 when it has indicia of reliability. The Illinois Department
19 may withhold payments without first notifying the provider or
20 alternate payee of its intention to withhold such payments. A
21 provider or alternate payee may request a hearing or a
22 reconsideration of payment withholding, and the Illinois
23 Department must grant such a request. The Illinois Department
24 shall state by rule a process and criteria by which a provider
25 or alternate payee may request a hearing or a reconsideration
26 for the full or partial release of payments withheld under
SB3365 Enrolled - 474 - LRB104 18483 SSS 31925 b
1 this subsection. This request may be made at any time after the
2 Illinois Department first withholds such payments.
3 (a) The Illinois Department must send notice of its
4 withholding of program payments within 5 days of taking
5 such action. The notice must set forth the general
6 allegations as to the nature of the withholding action but
7 need not disclose any specific information concerning its
8 ongoing investigation. The notice must do all of the
9 following:
10 (1) State that payments are being withheld in
11 accordance with this subsection.
12 (2) State that the withholding is for a temporary
13 period, as stated in paragraph (b) of this subsection,
14 and cite the circumstances under which withholding
15 will be terminated.
16 (3) Specify, when appropriate, which type or types
17 of claims are withheld.
18 (4) Inform the provider or alternate payee of the
19 right to request a hearing or a reconsideration of the
20 withholding by the Illinois Department, including the
21 ability to submit written evidence.
22 (5) Inform the provider or alternate payee that a
23 written request may be made to the Illinois Department
24 for a hearing or a reconsideration for the full or
25 partial release of withheld payments and that such
26 requests may be made at any time after the Illinois
SB3365 Enrolled - 475 - LRB104 18483 SSS 31925 b
1 Department first withholds such payments.
2 (b) All withholding of payment actions under this
3 subsection shall be temporary and shall not continue after
4 any of the following:
5 (1) The Illinois Department determines that there
6 is insufficient evidence of fraud, or the provider or
7 alternate payee demonstrates clear cooperation with
8 the Illinois Department, as determined by the Illinois
9 Department, such that the circumstances do not give
10 rise to the need for withholding of payments; or
11 (2) The withholding of payments has lasted for a
12 period in excess of 3 years.
13 (c) The Illinois Department may adopt all rules
14 necessary to implement this subsection (K-5).
15 (L) The Illinois Department shall establish a protocol to
16 enable health care providers to disclose an actual or
17 potential violation of this Section pursuant to a
18 self-referral disclosure protocol, referred to in this
19 subsection as "the protocol". The protocol shall include
20 direction for health care providers on a specific person,
21 official, or office to whom such disclosures shall be made.
22 The Illinois Department shall post information on the protocol
23 on the Illinois Department's public website. The Illinois
24 Department may adopt rules necessary to implement this
25 subsection (L). In addition to other factors that the Illinois
26 Department finds appropriate, the Illinois Department may
SB3365 Enrolled - 476 - LRB104 18483 SSS 31925 b
1 consider a health care provider's timely use or failure to use
2 the protocol in considering the provider's failure to comply
3 with this Code.
4 (M) Notwithstanding any other provision of this Code, the
5 Illinois Department, at its discretion, may exempt an entity
6 licensed under the Nursing Home Care Act, the ID/DD Community
7 Care Act, or the MC/DD Act from the provisions of subsections
8 (A-15), (B), and (C) of this Section if the licensed entity is
9 in receivership.
10 (N) Enforcement of advance payment agreements. To the
11 extent not prohibited by federal or State law, and
12 notwithstanding any other provision of this Code, if a
13 provider fails to comply with the terms of an advance payment
14 agreement, the Department is authorized to collect any unpaid
15 advance balance through one or more of the following methods:
16 (1) Direct withholding of Department reimbursements.
17 The Department may withhold reimbursement or other amounts
18 otherwise payable by the Department to the provider,
19 including, but not limited to, fee-for-service claims
20 payments, supplemental payments, and any other amounts the
21 Department is obligated to pay the provider under the
22 medical assistance program, and apply such withheld
23 amounts as repayment of the unpaid advance.
24 (2) Managed care organizations remittance. If a
25 provider participates in a managed care program
26 administered by the Department, the Department may direct
SB3365 Enrolled - 477 - LRB104 18483 SSS 31925 b
1 the managed care organization to remit to the Department
2 amounts otherwise payable by the managed care organization
3 to the provider, and apply such remitted amounts as
4 repayment of the unpaid advance.
5 (3) Interagency recoupment. The Department may recoup
6 amounts otherwise payable by any State agency to the
7 provider, including, but not limited to, State grants and
8 grant appropriations, and apply such amounts as repayment
9 of the unpaid advance.
10 (4) Other collection methods. The Department may
11 pursue any other collection remedy available at law.
12 The Department shall adopt rules establishing procedures
13 for collection under this subsection (N). For purposes of this
14 subsection (N), "provider" includes, but is not limited to, a
15 long-term care facility as defined under the Nursing Home Care
16 Act and a hospital provider as defined under Article V-A of
17 this Code.
18 (Source: P.A. 102-538, eff. 8-20-21.)
19 ARTICLE 260.
20 Section 260-5. The Illinois Administrative Procedure Act
21 is amended by adding Section 5-45.73 as follows:
22 (5 ILCS 100/5-45.73 new)
23 Sec. 5-45.73. Emergency rulemaking; nursing home staffing
SB3365 Enrolled - 478 - LRB104 18483 SSS 31925 b
1 ratios. To provide for the expeditious and timely
2 implementation of Section 3-202.05 of the Nursing Home Care
3 Act and changes made by this amendatory Act of the 104th
4 General Assembly to Section 3-202.05 of the Nursing Home Care
5 Act, emergency rules implementing Section 3-202.05 of the
6 Nursing Home Care Act and changes made by this amendatory Act
7 of the 104th General Assembly to Section 3-202.05 of the
8 Nursing Home Care Act may be adopted in accordance with
9 Section 5-45 by the Department of Public Health. The adoption
10 of emergency rules authorized by Section 5-45 and this Section
11 is deemed to be necessary for the public interest, safety, and
12 welfare.
13 This Section is repealed one year after the effective date
14 of this amendatory Act of the 104th General Assembly.
15 Section 260-10. The Nursing Home Care Act is amended by
16 changing Section 3-202.05 and by adding Section 3-130 as
17 follows:
18 (210 ILCS 45/3-130 new)
19 Sec. 3-130. Annual training for facility staff. A facility
20 must provide its staff with annual training based on the most
21 recurrent citations as specified by the Department. The annual
22 training requirements will be defined by the Department
23 annually based on the most frequent and recurrent findings or
24 citations during surveys or complaint investigations. The
SB3365 Enrolled - 479 - LRB104 18483 SSS 31925 b
1 facility must provide proof or documentation of the annual
2 training performed for the recurrent violations. Failure to
3 provide such proof or documentation may result in
4 administrative fines and penalties under this Act. The
5 Department may adopt any rules necessary to implement this
6 Section.
7 The provisions of this Section are declarative of existing
8 law.
9 (210 ILCS 45/3-202.05)
10 Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
11 thereafter.
12 (a) For the purpose of computing staff to resident ratios,
13 direct care staff shall include:
14 (1) registered nurses;
15 (2) licensed practical nurses;
16 (3) certified nurse assistants;
17 (4) psychiatric services rehabilitation aides;
18 (5) rehabilitation and therapy aides;
19 (6) psychiatric services rehabilitation coordinators;
20 (7) assistant directors of nursing;
21 (8) 50% of the Director of Nurses' time; and
22 (9) 30% of the Social Services Directors' time.
23 The Department shall, by rule, allow certain facilities
24 subject to 77 Ill. Adm. Code 300.4000 and following (Subpart
25 S) to utilize specialized clinical staff, as defined in rules,
SB3365 Enrolled - 480 - LRB104 18483 SSS 31925 b
1 to count towards the staffing ratios.
2 Within 120 days of June 14, 2012 (the effective date of
3 Public Act 97-689), the Department shall promulgate rules
4 specific to the staffing requirements for facilities federally
5 defined as Institutions for Mental Disease. These rules shall
6 recognize the unique nature of individuals with chronic mental
7 health conditions, shall include minimum requirements for
8 specialized clinical staff, including clinical social workers,
9 psychiatrists, psychologists, and direct care staff set forth
10 in paragraphs (4) through (6) and any other specialized staff
11 which may be utilized and deemed necessary to count toward
12 staffing ratios.
13 Within 120 days of June 14, 2012 (the effective date of
14 Public Act 97-689), the Department shall promulgate rules
15 specific to the staffing requirements for facilities licensed
16 under the Specialized Mental Health Rehabilitation Act of
17 2013. These rules shall recognize the unique nature of
18 individuals with chronic mental health conditions, shall
19 include minimum requirements for specialized clinical staff,
20 including clinical social workers, psychiatrists,
21 psychologists, and direct care staff set forth in paragraphs
22 (4) through (6) and any other specialized staff which may be
23 utilized and deemed necessary to count toward staffing ratios.
24 (a-5) The Centers for Medicare and Medicaid Services'
25 payroll-based journal job title codes, which correspond to the
26 staff used for the staffing ratios in subsection (a), are as
SB3365 Enrolled - 481 - LRB104 18483 SSS 31925 b
1 follows:
2 (1) Registered Nurse Director of Nursing, job title
3 code 5.
4 (2) Registered Nurse with Administrative Duties, job
5 title code 6.
6 (3) Registered Nurse, job title code 7.
7 (4) Licensed Practical/Vocational Nurse with
8 Administrative Duties, job title code 8.
9 (5) Licensed Practical/Vocational Nurse, job title
10 code 9.
11 (6) Certified Nurse Aide, job title code 10.
12 (7) Nurse Aide in Training, job title code 11.
13 (8) Medication Aide/Technician, job title code 12.
14 (9) Nurse Practitioner, job title code 13.
15 (10) Clinical Nurse Specialist, job title code 14.
16 (11) Occupational Therapist, job title code 18.
17 (12) Occupational Therapy Assistant, job title code
18 19.
19 (13) Occupational Therapy Aide, job title code 20.
20 (14) Physical Therapist, job title code 21.
21 (15) Physical Therapy Assistant, job title code 22.
22 (16) Physical Therapy Assistant, job title code 23.
23 (17) Respiratory Therapist, job title code 24.
24 (18) Respiratory Therapy Technician, job title code
25 25.
26 (19) Speech/Language Pathologist, job title code 26.
SB3365 Enrolled - 482 - LRB104 18483 SSS 31925 b
1 (20) Qualified Activities Professional, job title code
2 28.
3 (21) Other Activities Staff, job title code 29.
4 (22) Qualified Social Worker, job title code 30.
5 (23) Other Social Worker, job title code 31.
6 (24) Mental Health Service Worker, job title code 34.
7 For all job title codes in this subsection, 100% of the
8 hours worked by the staff must be counted toward the
9 staff-to-resident ratio, except job code title 5, which is
10 limited to 50%, and job title codes 28, 30, and 31, which are
11 limited to 30%.
12 (b) (Blank).
13 (b-5) For purposes of the minimum staffing ratios in this
14 Section, all residents shall be classified as requiring either
15 skilled care or intermediate care.
16 As used in this subsection:
17 "Intermediate care" means basic nursing care and other
18 restorative services under periodic medical direction.
19 "Skilled care" means skilled nursing care, continuous
20 skilled nursing observations, restorative nursing, and other
21 services under professional direction with frequent medical
22 supervision.
23 (c) Facilities shall notify the Department within 60 days
24 after July 29, 2010 (the effective date of Public Act
25 96-1372), in a form and manner prescribed by the Department,
26 of the staffing ratios in effect on July 29, 2010 (the
SB3365 Enrolled - 483 - LRB104 18483 SSS 31925 b
1 effective date of Public Act 96-1372) for both intermediate
2 and skilled care and the number of residents receiving each
3 level of care.
4 (d)(1) (Blank).
5 (2) (Blank).
6 (3) (Blank).
7 (4) (Blank).
8 (5) Effective January 1, 2014, the minimum staffing ratios
9 shall be increased to 3.8 hours of nursing and personal care
10 each day for a resident needing skilled care and 2.5 hours of
11 nursing and personal care each day for a resident needing
12 intermediate care.
13 (e) Ninety days after June 14, 2012 (the effective date of
14 Public Act 97-689), a minimum of 25% of nursing and personal
15 care time shall be provided by licensed nurses, with at least
16 10% of nursing and personal care time provided by registered
17 nurses. These minimum requirements shall remain in effect
18 until an acuity based registered nurse requirement is
19 promulgated by rule concurrent with the adoption of the
20 Resource Utilization Group classification-based payment
21 methodology, as provided in Section 5-5.2 of the Illinois
22 Public Aid Code. Registered nurses and licensed practical
23 nurses employed by a facility in excess of these requirements
24 may be used to satisfy the remaining 75% of the nursing and
25 personal care time requirements. Notwithstanding this
26 subsection, no staffing requirement in statute in effect on
SB3365 Enrolled - 484 - LRB104 18483 SSS 31925 b
1 June 14, 2012 (the effective date of Public Act 97-689) shall
2 be reduced on account of this subsection.
3 (f) The Department shall propose rules as are necessary to
4 implement the provisions of this Section and consistent with
5 this amendatory Act of the 104th General Assembly within 60
6 days after the effective date of this amendatory Act of the
7 104th General Assembly. submit proposed rules for adoption by
8 January 1, 2020 establishing a system for determining
9 compliance with minimum staffing set forth in this Section and
10 the requirements of 77 Ill. Adm. Code 300.1230 adjusted for
11 any waivers granted under Section 3-303.1. Compliance with
12 minimum staffing as required by this Section shall be
13 determined on a quarterly basis. The Department shall
14 determine compliance by comparing the number of hours provided
15 per resident per day using the Centers for Medicare and
16 Medicaid Services' payroll-based journal and the facility's
17 daily census, broken down by intermediate and skilled care as
18 self-reported by the facility to the Department on a quarterly
19 basis. As used in this subsection, "quarterly basis" means the
20 Centers for Medicare and Medicaid Services' quarterly
21 reporting periods for the federal fiscal year. The Department
22 shall use the quarterly payroll-based journal and the
23 self-reported census to calculate the number of hours provided
24 per resident per day and compare this ratio to the minimum
25 staffing standards required under this Section, as impacted by
26 any waivers granted under Section 3-303.1. Discrepancies
SB3365 Enrolled - 485 - LRB104 18483 SSS 31925 b
1 between job titles contained in this Section and the
2 payroll-based journal shall be addressed by rule. The manner
3 in which the Department requests payroll-based journal
4 information to be submitted shall align with the federal
5 Centers for Medicare and Medicaid Services' requirements that
6 allow providers to submit the quarterly data in an aggregate
7 manner.
8 (g) Monetary penalties for non-compliance. The Department
9 shall propose rules that are necessary to implement the
10 provisions of this Section, consistent with the changes made
11 by this amendatory Act of the 104th General Assembly, within
12 60 days after the effective date of this amendatory Act of the
13 104th General Assembly. submit proposed rules for adoption by
14 January 1, 2020 establishing monetary penalties for facilities
15 not in compliance with minimum staffing standards under this
16 Section. Facilities shall be required to comply with the
17 provisions of this subsection beginning January 1, 2025. No
18 monetary penalty may be issued for noncompliance prior to the
19 revised implementation date, which shall be January 1, 2025.
20 If a facility is found to be noncompliant prior to the revised
21 implementation date, the Department shall provide a written
22 notice identifying the staffing deficiencies and require the
23 facility to provide a sufficiently detailed correction plan
24 that describes proposed and completed actions the facility
25 will take or has taken, including hiring actions, to address
26 the facility's failure to meet the statutory minimum staffing
SB3365 Enrolled - 486 - LRB104 18483 SSS 31925 b
1 levels. Monetary penalties shall be imposed beginning no later
2 than July 1, 2025, based on data for the quarter beginning July
3 1, 2026 through September 30, 2026 January 1, 2025 through
4 March 31, 2025 and quarterly thereafter. Monetary penalties
5 shall be assessed on a quarterly basis and established based
6 on a formula that calculates on a daily basis the cost of wages
7 and benefits for the missing staffing hours. All notices of
8 noncompliance shall include the computations used to determine
9 noncompliance and establishing the variance between minimum
10 staffing ratios and the Department's computations. The penalty
11 for the first offense shall be 125% of the cost of wages and
12 benefits for the missing staffing hours. The penalty shall
13 increase to 150% of the cost of wages and benefits for the
14 missing staffing hours for the second offense and 200% the
15 cost of wages and benefits for the missing staffing hours for
16 the third and all subsequent offenses. The penalty shall be
17 imposed regardless of whether the facility has committed other
18 violations of this Act during the same period that the
19 staffing offense occurred. The penalty may not be waived,
20 except where there is no more than a 10% deviation from the
21 staffing requirements, in which case the facility shall not
22 receive a violation or penalty. The Department shall:
23 (1) when calculating whether there is no more than a
24 10% deviation from the staffing requirements, determine
25 the deviation based only on days of the quarter where a
26 facility failed to meet the minimum staffing requirements;
SB3365 Enrolled - 487 - LRB104 18483 SSS 31925 b
1 and
2 (2) only assess penalties against categories of
3 payroll-based journal job titles that deviate from the
4 staffing requirements by more than 10%. Categories include
5 registered nurses, licensed practical nurses, and other
6 payroll-based journal job titles, as determined by the
7 required staffing levels in subsection (e) of this Section
8 and as listed in subsections (a) and (a-5) of this
9 Section. Penalties shall not be assessed against
10 categories of payroll-based journal job titles that have
11 no more than a 10% deviation from staffing requirements.
12 The Department is granted discretion to waive the
13 violation and penalty when unforeseen circumstances have
14 occurred that resulted in call-offs of scheduled staff. This
15 provision shall be applied no more than 6 times per quarter.
16 Nothing in this Section diminishes a facility's right to
17 appeal the imposition of a monetary penalty. No facility may
18 appeal a notice of noncompliance issued during the revised
19 implementation period. The changes made to this subsection by
20 this amendatory Act of the 104th General Assembly in regard to
21 nursing home staffing fines shall apply to the July 1, 2025
22 fines based on data for the quarter beginning July 1, 2026
23 through September 30, 2026, January 1, 2025 through March 31,
24 2025 and quarterly thereafter.
25 (Source: P.A. 104-9, eff. 6-16-25.)
SB3365 Enrolled - 488 - LRB104 18483 SSS 31925 b
1 Section 260-15. The Illinois Public Aid Code is amended by
2 changing Sections 5-5.2 and 12-4.25 as follows:
3 (305 ILCS 5/5-5.2)
4 Sec. 5-5.2. Payment.
5 (a) All nursing facilities that are grouped pursuant to
6 Section 5-5.1 of this Act shall receive the same rate of
7 payment for similar services.
8 (b) It shall be a matter of State policy that the Illinois
9 Department shall utilize a uniform billing cycle throughout
10 the State for the long-term care providers.
11 (c) (Blank).
12 (c-1) Notwithstanding any other provisions of this Code,
13 the methodologies for reimbursement of nursing services as
14 provided under this Article shall no longer be applicable for
15 bills payable for nursing services rendered on or after a new
16 reimbursement system based on the Patient Driven Payment Model
17 (PDPM) has been fully operationalized, which shall take effect
18 for services provided on or after the implementation of the
19 PDPM reimbursement system begins. For the purposes of Public
20 Act 102-1035, the implementation date of the PDPM
21 reimbursement system and all related provisions shall be July
22 1, 2022 if the following conditions are met: (i) the Centers
23 for Medicare and Medicaid Services has approved corresponding
24 changes in the reimbursement system and bed assessment; and
25 (ii) the Department has filed rules to implement these changes
SB3365 Enrolled - 489 - LRB104 18483 SSS 31925 b
1 no later than June 1, 2022. Failure of the Department to file
2 rules to implement the changes provided in Public Act 102-1035
3 no later than June 1, 2022 shall result in the implementation
4 date being delayed to October 1, 2022.
5 (d) The new nursing services reimbursement methodology
6 utilizing the Patient Driven Payment Model, which shall be
7 referred to as the PDPM reimbursement system, taking effect
8 July 1, 2022, upon federal approval by the Centers for
9 Medicare and Medicaid Services, shall be based on the
10 following:
11 (1) The methodology shall be resident-centered,
12 facility-specific, cost-based, and based on guidance from
13 the Centers for Medicare and Medicaid Services.
14 (2) Costs shall be annually rebased and case mix index
15 quarterly updated. The nursing services methodology will
16 be assigned to the Medicaid enrolled residents on record
17 as of 30 days prior to the beginning of the rate period in
18 the Department's Medicaid Management Information System
19 (MMIS) as present on the last day of the second quarter
20 preceding the rate period based upon the Assessment
21 Reference Date of the Minimum Data Set (MDS).
22 (3) Regional wage adjustors based on the Health
23 Service Areas (HSA) groupings and adjusters in effect on
24 April 30, 2012 shall be included, except no adjuster shall
25 be lower than 1.06.
26 (4) PDPM nursing case mix indices in effect on March
SB3365 Enrolled - 490 - LRB104 18483 SSS 31925 b
1 1, 2022 shall be assigned to each resident class at no less
2 than 0.7858 of the Centers for Medicare and Medicaid
3 Services PDPM unadjusted case mix values, in effect on
4 March 1, 2022.
5 (5) The pool of funds available for distribution by
6 case mix and the base facility rate shall be determined
7 using the formula contained in subsection (d-1).
8 (6) The Department shall establish a variable per diem
9 staffing add-on in accordance with the most recent
10 available federal staffing report, currently the Payroll
11 Based Journal, for the same period of time, and if
12 applicable adjusted for acuity using the same quarter's
13 MDS. The Department shall rely on Payroll Based Journals
14 provided to the Department of Public Health to make a
15 determination of non-submission. If the Department is
16 notified by a facility of missing or inaccurate Payroll
17 Based Journal data or an incorrect calculation of
18 staffing, the Department must make a correction as soon as
19 the error is verified for the applicable quarter.
20 Beginning October 1, 2024, the staffing percentage
21 used in the calculation of the per diem staffing add-on
22 shall be its PDPM STRIVE Staffing Ratio which equals: its
23 Reported Total Nurse Staffing Hours Per Resident Per Day
24 as published in the most recent federal staffing report
25 (the Provider Information File), divided by the facility's
26 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
SB3365 Enrolled - 491 - LRB104 18483 SSS 31925 b
1 Staffing Target is equal to .82 times the facility's
2 Illinois Adjusted Facility Case-Mix Hours Per Resident Per
3 Day. A facility's Illinois Adjusted Facility Case Mix
4 Hours Per Resident Per Day is equal to its Case-Mix Total
5 Nurse Staffing Hours Per Resident Per Day (as published in
6 the most recent federal Provider Information file) times
7 3.662 (which reflects the national resident days-weighted
8 mean Reported Total Nurse Staffing Hours Per Resident Per
9 Day as calculated using the January 2024 federal Provider
10 Information Files), divided by the national resident
11 days-weighted mean Reported Total Nurse Staffing Hours Per
12 Resident Per Day calculated using the most recent State US
13 Averages file.
14 Beginning January 1, 2025, the staffing percentage
15 used in the calculation of the per diem staffing add-on
16 shall be its PDPM STRIVE Staffing Ratio which equals: its
17 Reported Total Nurse Staffing Hours Per Resident Per Day
18 as published in the most recent federal staffing report
19 (the Provider Information File), divided by the facility's
20 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
21 Staffing Target is equal to .7122 times the facility's
22 Illinois Adjusted Facility Case-Mix Hours Per Resident Per
23 Day. A facility's Illinois Adjusted Facility Case Mix
24 Hours Per Resident Per Day is equal to its Case-Mix Total
25 Nurse Staffing Hours Per Resident Per Day (as published in
26 the most recent federal staffing report Provider
SB3365 Enrolled - 492 - LRB104 18483 SSS 31925 b
1 Information file) times 3.79 (which is the Reported Total
2 Nurse Staffing Hours Per Resident Per Day for the Nation
3 as reported the January 2024 State US Averages file),
4 divided by the Reported Total Nurse Staffing Hours Per
5 Resident Per Day for the Nation as reported in the most
6 recent State US Averages file.
7 (6.5) Beginning July 1, 2024, the paid per diem
8 staffing add-on shall be the paid per diem staffing add-on
9 in effect April 1, 2024. For dates beginning October 1,
10 2024 and through September 30, 2025, the denominator for
11 the staffing percentage shall be the lesser of the
12 facility's PDPM STRIVE Staffing Target and:
13 (A) For the quarter beginning October 1, 2024, the
14 sum of 20% of the facility's PDPM STRIVE Staffing
15 Target and 80% of the facility's Case-Mix Total Nurse
16 Staffing Hours Per Resident Per Day (as published in
17 the January 2024 federal staffing report).
18 (B) For the quarter beginning January 1, 2025, the
19 sum of 40% of the facility's PDPM STRIVE Staffing
20 Target and 60% of the facility's Case-Mix Total Nurse
21 Staffing Hours Per Resident Per Day (as published in
22 the January 2024 federal staffing report).
23 (C) For the quarter beginning March 1, 2025, the
24 sum of 60% of the facility's PDPM STRIVE Staffing
25 Target and 40% of the facility's Case-Mix Total Nurse
26 Staffing Hours Per Resident Per Day (as published in
SB3365 Enrolled - 493 - LRB104 18483 SSS 31925 b
1 the January 2024 federal staffing report).
2 (D) For the quarter beginning July 1, 2025, the
3 sum of 80% of the facility's PDPM STRIVE Staffing
4 Target and 20% of the facility's Case-Mix Total Nurse
5 Staffing Hours Per Resident Per Day (as published in
6 the January 2024 federal staffing report).
7 Facilities with at least 70% of the staffing
8 indicated by the STRIVE study shall be paid a per diem
9 add-on of $9, increasing by equivalent steps for each
10 whole percentage point until the facilities reach a per
11 diem of $16.52. Facilities with at least 80% of the
12 staffing indicated by the STRIVE study shall be paid a per
13 diem add-on of $16.52, increasing by equivalent steps for
14 each whole percentage point until the facilities reach a
15 per diem add-on of $25.77. Facilities with at least 92% of
16 the staffing indicated by the STRIVE study shall be paid a
17 per diem add-on of $25.77, increasing by equivalent steps
18 for each whole percentage point until the facilities reach
19 a per diem add-on of $30.98. Facilities with at least 100%
20 of the staffing indicated by the STRIVE study shall be
21 paid a per diem add-on of $30.98, increasing by equivalent
22 steps for each whole percentage point until the facilities
23 reach a per diem add-on of $36.44. Facilities with at
24 least 110% of the staffing indicated by the STRIVE study
25 shall be paid a per diem add-on of $36.44, increasing by
26 equivalent steps for each whole percentage point until the
SB3365 Enrolled - 494 - LRB104 18483 SSS 31925 b
1 facilities reach a per diem add-on of $38.68. Facilities
2 with at least 125% or higher of the staffing indicated by
3 the STRIVE study shall be paid a per diem add-on of $38.68.
4 No nursing facility's variable staffing per diem add-on
5 shall be reduced by more than 5% in 2 consecutive
6 quarters. For the quarters beginning July 1, 2022 and
7 October 1, 2022, no facility's variable per diem staffing
8 add-on shall be calculated at a rate lower than 85% of the
9 staffing indicated by the STRIVE study. No facility below
10 70% of the staffing indicated by the STRIVE study shall
11 receive a variable per diem staffing add-on after December
12 31, 2022.
13 Beginning January 1, 2027, a $2.25 rate increase shall
14 be added to each STRIVE staffing per diem add-on under
15 subparagraph (D) of this paragraph (6.5) for facilities
16 with at least 80% of the staffing indicated by the STRIVE
17 study.
18 (7) For dates of services beginning July 1, 2022, the
19 PDPM nursing component per diem for each nursing facility
20 shall be the product of the facility's (i) statewide PDPM
21 nursing base per diem rate, $92.25, adjusted for the
22 facility average PDPM case mix index calculated quarterly
23 and (ii) the regional wage adjuster, and then add the
24 Medicaid access adjustment as defined in (e-3) of this
25 Section. Transition rates for services provided between
26 July 1, 2022 and October 1, 2023 shall be the greater of
SB3365 Enrolled - 495 - LRB104 18483 SSS 31925 b
1 the PDPM nursing component per diem or:
2 (A) for the quarter beginning July 1, 2022, the
3 RUG-IV nursing component per diem;
4 (B) for the quarter beginning October 1, 2022, the
5 sum of the RUG-IV nursing component per diem
6 multiplied by 0.80 and the PDPM nursing component per
7 diem multiplied by 0.20;
8 (C) for the quarter beginning January 1, 2023, the
9 sum of the RUG-IV nursing component per diem
10 multiplied by 0.60 and the PDPM nursing component per
11 diem multiplied by 0.40;
12 (D) for the quarter beginning April 1, 2023, the
13 sum of the RUG-IV nursing component per diem
14 multiplied by 0.40 and the PDPM nursing component per
15 diem multiplied by 0.60;
16 (E) for the quarter beginning July 1, 2023, the
17 sum of the RUG-IV nursing component per diem
18 multiplied by 0.20 and the PDPM nursing component per
19 diem multiplied by 0.80; or
20 (F) for the quarter beginning October 1, 2023 and
21 each subsequent quarter, the transition rate shall end
22 and a nursing facility shall be paid 100% of the PDPM
23 nursing component per diem.
24 (d-1) Calculation of base year Statewide RUG-IV nursing
25 base per diem rate.
26 (1) Base rate spending pool shall be:
SB3365 Enrolled - 496 - LRB104 18483 SSS 31925 b
1 (A) The base year resident days which are
2 calculated by multiplying the number of Medicaid
3 residents in each nursing home as indicated in the MDS
4 data defined in paragraph (4) by 365.
5 (B) Each facility's nursing component per diem in
6 effect on July 1, 2012 shall be multiplied by
7 subsection (A).
8 (C) Thirteen million is added to the product of
9 subparagraph (A) and subparagraph (B) to adjust for
10 the exclusion of nursing homes defined in paragraph
11 (5).
12 (2) For each nursing home with Medicaid residents as
13 indicated by the MDS data defined in paragraph (4),
14 weighted days adjusted for case mix and regional wage
15 adjustment shall be calculated. For each home this
16 calculation is the product of:
17 (A) Base year resident days as calculated in
18 subparagraph (A) of paragraph (1).
19 (B) The nursing home's regional wage adjustor
20 based on the Health Service Areas (HSA) groupings and
21 adjustors in effect on April 30, 2012.
22 (C) Facility weighted case mix which is the number
23 of Medicaid residents as indicated by the MDS data
24 defined in paragraph (4) multiplied by the associated
25 case weight for the RUG-IV 48 grouper model using
26 standard RUG-IV procedures for index maximization.
SB3365 Enrolled - 497 - LRB104 18483 SSS 31925 b
1 (D) The sum of the products calculated for each
2 nursing home in subparagraphs (A) through (C) above
3 shall be the base year case mix, rate adjusted
4 weighted days.
5 (3) The Statewide RUG-IV nursing base per diem rate:
6 (A) on January 1, 2014 shall be the quotient of the
7 paragraph (1) divided by the sum calculated under
8 subparagraph (D) of paragraph (2);
9 (B) on and after July 1, 2014 and until July 1,
10 2022, shall be the amount calculated under
11 subparagraph (A) of this paragraph (3) plus $1.76; and
12 (C) beginning July 1, 2022 and thereafter, $7
13 shall be added to the amount calculated under
14 subparagraph (B) of this paragraph (3) of this
15 Section.
16 (4) Minimum Data Set (MDS) comprehensive assessments
17 for Medicaid residents on the last day of the quarter used
18 to establish the base rate.
19 (5) Nursing facilities designated as of July 1, 2012
20 by the Department as "Institutions for Mental Disease"
21 shall be excluded from all calculations under this
22 subsection. The data from these facilities shall not be
23 used in the computations described in paragraphs (1)
24 through (4) above to establish the base rate.
25 (e) Beginning July 1, 2014, the Department shall allocate
26 funding in the amount up to $10,000,000 for per diem add-ons to
SB3365 Enrolled - 498 - LRB104 18483 SSS 31925 b
1 the RUGS methodology for dates of service on and after July 1,
2 2014:
3 (1) $0.63 for each resident who scores in I4200
4 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
5 (2) $2.67 for each resident who scores either a "1" or
6 "2" in any items S1200A through S1200I and also scores in
7 RUG groups PA1, PA2, BA1, or BA2.
8 (e-1) (Blank).
9 (e-2) For dates of services beginning January 1, 2014 and
10 ending September 30, 2023, the RUG-IV nursing component per
11 diem for a nursing home shall be the product of the statewide
12 RUG-IV nursing base per diem rate, the facility average case
13 mix index, and the regional wage adjustor. For dates of
14 service beginning July 1, 2022 and ending September 30, 2023,
15 the Medicaid access adjustment described in subsection (e-3)
16 shall be added to the product.
17 (e-3) A Medicaid Access Adjustment of $4 adjusted for the
18 facility average PDPM case mix index calculated quarterly
19 shall be added to the statewide PDPM nursing per diem for all
20 facilities with annual Medicaid bed days of at least 70% of all
21 occupied bed days adjusted quarterly. For each new calendar
22 year and for the 6-month period beginning July 1, 2022, the
23 percentage of a facility's occupied bed days comprised of
24 Medicaid bed days shall be determined by the Department
25 quarterly. For dates of service beginning January 1, 2023, the
26 Medicaid Access Adjustment shall be increased to $4.75. This
SB3365 Enrolled - 499 - LRB104 18483 SSS 31925 b
1 subsection shall be inoperative on and after December 31, 2029
2 January 1, 2028.
3 (e-3.5) For dates of service beginning January 1, 2027,
4 the Medicaid Access Adjustment shall be increased by $5.55 to
5 $10.30 per diem for those facilities with at least 70% of the
6 staffing indicated by the STRIVE study as described in
7 subparagraph (D) of paragraph (6.5) of subsection (d). A
8 facility shall be eligible for Medicaid Access Adjustment
9 described in this subsection (e-3.5) only if the facility
10 demonstrates compliance with the training requirements for
11 staff outlined in Section 3-130 of the Nursing Home Care Act.
12 This subsection (e-3.5) shall be inoperative on and after
13 December 31, 2029.
14 (e-3.6) For dates of service beginning January 1, 2027,
15 facilities located outside of Rate Areas 6, 7, and 8 that have
16 Medicaid bed days of at least 65% of all occupied bed days
17 adjusted quarterly shall qualify for the Medicaid Access
18 Adjustment described in subsections (e-3) and (e-3.5).
19 Facilities located inside Rate Areas 6, 7, and 8 shall have
20 their threshold remain at 70% for all qualifying facilities
21 described in subsections (e-3) and (e-3.5). This subsection
22 (e-3.6) shall be inoperative on and after December 31, 2029.
23 (e-4) Subject to federal approval, on and after January 1,
24 2024, the Department shall increase the rate add-on at
25 paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
26 for ventilator services from $208 per day to $481 per day.
SB3365 Enrolled - 500 - LRB104 18483 SSS 31925 b
1 Payment is subject to the criteria and requirements under 89
2 Ill. Adm. Code 147.335.
3 (f) (Blank).
4 (g) Notwithstanding any other provision of this Code, on
5 and after July 1, 2012, for facilities not designated by the
6 Department of Healthcare and Family Services as "Institutions
7 for Mental Disease", rates effective May 1, 2011 shall be
8 adjusted as follows:
9 (1) (Blank);
10 (2) (Blank);
11 (3) Facility rates for the capital and support
12 components shall be reduced by 1.7%.
13 (h) Notwithstanding any other provision of this Code, on
14 and after July 1, 2012, nursing facilities designated by the
15 Department of Healthcare and Family Services as "Institutions
16 for Mental Disease" and "Institutions for Mental Disease" that
17 are facilities licensed under the Specialized Mental Health
18 Rehabilitation Act of 2013 shall have the nursing,
19 socio-developmental, capital, and support components of their
20 reimbursement rate effective May 1, 2011 reduced in total by
21 2.7%.
22 (i) On and after July 1, 2014, the reimbursement rates for
23 the support component of the nursing facility rate for
24 facilities licensed under the Nursing Home Care Act as skilled
25 or intermediate care facilities shall be the rate in effect on
26 June 30, 2014 increased by 8.17%.
SB3365 Enrolled - 501 - LRB104 18483 SSS 31925 b
1 (i-1) Subject to federal approval, on and after January 1,
2 2024, the reimbursement rates for the support component of the
3 nursing facility rate for facilities licensed under the
4 Nursing Home Care Act as skilled or intermediate care
5 facilities shall be the rate in effect on June 30, 2023
6 increased by 12%.
7 (j) Notwithstanding any other provision of law, subject to
8 federal approval, effective July 1, 2019, sufficient funds
9 shall be allocated for changes to rates for facilities
10 licensed under the Nursing Home Care Act as skilled nursing
11 facilities or intermediate care facilities for dates of
12 services on and after July 1, 2019: (i) to establish, through
13 June 30, 2022 a per diem add-on to the direct care per diem
14 rate not to exceed $70,000,000 annually in the aggregate
15 taking into account federal matching funds for the purpose of
16 addressing the facility's unique staffing needs, adjusted
17 quarterly and distributed by a weighted formula based on
18 Medicaid bed days on the last day of the second quarter
19 preceding the quarter for which the rate is being adjusted.
20 Beginning July 1, 2022, the annual $70,000,000 described in
21 the preceding sentence shall be dedicated to the variable per
22 diem add-on for staffing under paragraph (6) of subsection
23 (d); and (ii) in an amount not to exceed $170,000,000 annually
24 in the aggregate taking into account federal matching funds to
25 permit the support component of the nursing facility rate to
26 be updated as follows:
SB3365 Enrolled - 502 - LRB104 18483 SSS 31925 b
1 (1) 80%, or $136,000,000, of the funds shall be used
2 to update each facility's rate in effect on June 30, 2019
3 using the most recent cost reports on file, which have had
4 a limited review conducted by the Department of Healthcare
5 and Family Services and will not hold up enacting the rate
6 increase, with the Department of Healthcare and Family
7 Services.
8 (2) After completing the calculation in paragraph (1),
9 any facility whose rate is less than the rate in effect on
10 June 30, 2019 shall have its rate restored to the rate in
11 effect on June 30, 2019 from the 20% of the funds set
12 aside.
13 (3) The remainder of the 20%, or $34,000,000, shall be
14 used to increase each facility's rate by an equal
15 percentage.
16 (k) During the first quarter of State Fiscal Year 2020,
17 the Department of Healthcare of Family Services must convene a
18 technical advisory group consisting of members of all trade
19 associations representing Illinois skilled nursing providers
20 to discuss changes necessary with federal implementation of
21 Medicare's Patient-Driven Payment Model. Implementation of
22 Medicare's Patient-Driven Payment Model shall, by September 1,
23 2020, end the collection of the MDS data that is necessary to
24 maintain the current RUG-IV Medicaid payment methodology. The
25 technical advisory group must consider a revised reimbursement
26 methodology that takes into account transparency,
SB3365 Enrolled - 503 - LRB104 18483 SSS 31925 b
1 accountability, actual staffing as reported under the
2 federally required Payroll Based Journal system, changes to
3 the minimum wage, adequacy in coverage of the cost of care, and
4 a quality component that rewards quality improvements.
5 (l) The Department shall establish per diem add-on
6 payments to improve the quality of care delivered by
7 facilities, including:
8 (1) Incentive payments determined by facility
9 performance on specified quality measures in an initial
10 amount of $70,000,000. Nothing in this subsection shall be
11 construed to limit the quality of care payments in the
12 aggregate statewide to $70,000,000, and, if quality of
13 care has improved across nursing facilities, the
14 Department shall adjust those add-on payments accordingly.
15 The quality payment methodology described in this
16 subsection must be used for at least State Fiscal Year
17 2023. Beginning with the quarter starting July 1, 2023,
18 the Department may add, remove, or change quality metrics
19 and make associated changes to the quality payment
20 methodology as outlined in subparagraph (E). Facilities
21 designated by the Centers for Medicare and Medicaid
22 Services as a special focus facility or a hospital-based
23 nursing home do not qualify for quality payments.
24 (A) Each quality pool must be distributed by
25 assigning a quality weighted score for each nursing
26 home which is calculated by multiplying the nursing
SB3365 Enrolled - 504 - LRB104 18483 SSS 31925 b
1 home's quality base period Medicaid days by the
2 nursing home's star rating weight in that period.
3 (B) Star rating weights are assigned based on the
4 nursing home's star rating for the LTS quality star
5 rating. As used in this subparagraph, "LTS quality
6 star rating" means the long-term stay quality rating
7 for each nursing facility, as assigned by the Centers
8 for Medicare and Medicaid Services under the Five-Star
9 Quality Rating System. The rating is a number ranging
10 from 0 (lowest) to 5 (highest).
11 (i) Zero-star or one-star rating has a weight
12 of 0.
13 (ii) Two-star rating has a weight of 0.75.
14 (iii) Three-star rating has a weight of 1.5.
15 (iv) Four-star rating has a weight of 2.5.
16 (v) Five-star rating has a weight of 3.5.
17 (C) Each nursing home's quality weight score is
18 divided by the sum of all quality weight scores for
19 qualifying nursing homes to determine the proportion
20 of the quality pool to be paid to the nursing home.
21 (D) The quality pool is no less than $70,000,000
22 annually or $17,500,000 per quarter. The Department
23 shall publish on its website the estimated payments
24 and the associated weights for each facility 45 days
25 prior to when the initial payments for the quarter are
26 to be paid. The Department shall assign each facility
SB3365 Enrolled - 505 - LRB104 18483 SSS 31925 b
1 the most recent and applicable quarter's STAR value
2 unless the facility notifies the Department within 15
3 days of an issue and the facility provides reasonable
4 evidence demonstrating its timely compliance with
5 federal data submission requirements for the quarter
6 of record. If such evidence cannot be provided to the
7 Department, the STAR rating assigned to the facility
8 shall be reduced by one from the prior quarter.
9 (E) The Department shall review quality metrics
10 used for payment of the quality pool and make
11 recommendations for any associated changes to the
12 methodology for distributing quality pool payments in
13 consultation with associations representing long-term
14 care providers, consumer advocates, organizations
15 representing workers of long-term care facilities, and
16 payors. The Department may establish, by rule, changes
17 to the methodology for distributing quality pool
18 payments.
19 (F) The Department shall disburse quality pool
20 payments from the Long-Term Care Provider Fund on a
21 monthly basis in amounts proportional to the total
22 quality pool payment determined for the quarter.
23 (G) The Department shall publish any changes in
24 the methodology for distributing quality pool payments
25 prior to the beginning of the measurement period or
26 quality base period for any metric added to the
SB3365 Enrolled - 506 - LRB104 18483 SSS 31925 b
1 distribution's methodology.
2 (2) Payments based on CNA tenure, promotion, and CNA
3 training for the purpose of increasing CNA compensation.
4 It is the intent of this subsection that payments made in
5 accordance with this paragraph be directly incorporated
6 into increased compensation for CNAs. As used in this
7 paragraph, "CNA" means a certified nursing assistant as
8 that term is described in Section 3-206 of the Nursing
9 Home Care Act, Section 3-206 of the ID/DD Community Care
10 Act, and Section 3-206 of the MC/DD Act. The Department
11 shall establish, by rule, payments to nursing facilities
12 equal to Medicaid's share of the tenure wage increments
13 specified in this paragraph for all reported CNA employee
14 hours compensated according to a posted schedule
15 consisting of increments at least as large as those
16 specified in this paragraph. The increments are as
17 follows: an additional $1.50 per hour for CNAs with at
18 least one and less than 2 years' experience plus another
19 $1 per hour for each additional year of experience up to a
20 maximum of $6.50 for CNAs with at least 6 years of
21 experience. For purposes of this paragraph, Medicaid's
22 share shall be the ratio determined by paid Medicaid bed
23 days divided by total bed days for the applicable time
24 period used in the calculation. In addition, and additive
25 to any tenure increments paid as specified in this
26 paragraph, the Department shall establish, by rule,
SB3365 Enrolled - 507 - LRB104 18483 SSS 31925 b
1 payments supporting Medicaid's share of the
2 promotion-based wage increments for CNA employee hours
3 compensated for that promotion with at least a $1.50
4 hourly increase. Medicaid's share shall be established as
5 it is for the tenure increments described in this
6 paragraph. Qualifying promotions shall be defined by the
7 Department in rules for an expected 10-15% subset of CNAs
8 assigned intermediate, specialized, or added roles such as
9 CNA trainers, CNA scheduling "captains", and CNA
10 specialists for resident conditions like dementia or
11 memory care or behavioral health.
12 (m) The Department shall work with nursing facility
13 industry representatives to design policies and procedures to
14 permit facilities to address the integrity of data from
15 federal reporting sites used by the Department in setting
16 facility rates.
17 (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
18 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
19 Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
20 Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.
21 7-1-24; 103-1075, eff. 3-21-25.)
22 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
23 Sec. 12-4.25. Medical assistance program; vendor
24 participation.
25 (A) The Illinois Department may deny, suspend, or
SB3365 Enrolled - 508 - LRB104 18483 SSS 31925 b
1 terminate the eligibility of any person, firm, corporation,
2 association, agency, institution or other legal entity to
3 participate as a vendor of goods or services to recipients
4 under the medical assistance program under Article V, or may
5 exclude any such person or entity from participation as such a
6 vendor, and may deny, suspend, or recover payments, if after
7 reasonable notice and opportunity for a hearing the Illinois
8 Department finds:
9 (a) Such vendor is not complying with the Department's
10 policy or rules and regulations, or with the terms and
11 conditions prescribed by the Illinois Department in its
12 vendor agreement, which document shall be developed by the
13 Department as a result of negotiations with each vendor
14 category, including physicians, hospitals, long term care
15 facilities, pharmacists, optometrists, podiatric
16 physicians, and dentists setting forth the terms and
17 conditions applicable to the participation of each vendor
18 group in the program; or
19 (b) Such vendor has failed to keep or make available
20 for inspection, audit or copying, after receiving a
21 written request from the Illinois Department, such records
22 regarding payments claimed for providing services. This
23 section does not require vendors to make available patient
24 records of patients for whom services are not reimbursed
25 under this Code; or
26 (c) Such vendor has failed to furnish any information
SB3365 Enrolled - 509 - LRB104 18483 SSS 31925 b
1 requested by the Department regarding payments for
2 providing goods or services; or
3 (d) Such vendor has knowingly made, or caused to be
4 made, any false statement or representation of a material
5 fact in connection with the administration of the medical
6 assistance program; or
7 (e) Such vendor has furnished goods or services to a
8 recipient which are (1) in excess of need, (2) harmful, or
9 (3) of grossly inferior quality, all of such
10 determinations to be based upon competent medical judgment
11 and evaluations; or
12 (f) The vendor; a person with management
13 responsibility for a vendor; an officer or person owning,
14 either directly or indirectly, 5% or more of the shares of
15 stock or other evidences of ownership in a corporate
16 vendor; an owner of a sole proprietorship which is a
17 vendor; or a partner in a partnership which is a vendor,
18 either:
19 (1) was previously terminated, suspended, or
20 excluded from participation in the Illinois medical
21 assistance program, or was terminated, suspended, or
22 excluded from participation in another state or
23 federal medical assistance or health care program; or
24 (2) was a person with management responsibility
25 for a vendor previously terminated, suspended, or
26 excluded from participation in the Illinois medical
SB3365 Enrolled - 510 - LRB104 18483 SSS 31925 b
1 assistance program, or terminated, suspended, or
2 excluded from participation in another state or
3 federal medical assistance or health care program
4 during the time of conduct which was the basis for that
5 vendor's termination, suspension, or exclusion; or
6 (3) was an officer, or person owning, either
7 directly or indirectly, 5% or more of the shares of
8 stock or other evidences of ownership in a corporate
9 or limited liability company vendor previously
10 terminated, suspended, or excluded from participation
11 in the Illinois medical assistance program, or
12 terminated, suspended, or excluded from participation
13 in a state or federal medical assistance or health
14 care program during the time of conduct which was the
15 basis for that vendor's termination, suspension, or
16 exclusion; or
17 (4) was an owner of a sole proprietorship or
18 partner of a partnership previously terminated,
19 suspended, or excluded from participation in the
20 Illinois medical assistance program, or terminated,
21 suspended, or excluded from participation in a state
22 or federal medical assistance or health care program
23 during the time of conduct which was the basis for that
24 vendor's termination, suspension, or exclusion; or
25 (f-1) Such vendor has a delinquent debt owed to the
26 Illinois Department; or
SB3365 Enrolled - 511 - LRB104 18483 SSS 31925 b
1 (g) The vendor; a person with management
2 responsibility for a vendor; an officer or person owning,
3 either directly or indirectly, 5% or more of the shares of
4 stock or other evidences of ownership in a corporate or
5 limited liability company vendor; an owner of a sole
6 proprietorship which is a vendor; or a partner in a
7 partnership which is a vendor, either:
8 (1) has engaged in practices prohibited by
9 applicable federal or State law or regulation; or
10 (2) was a person with management responsibility
11 for a vendor at the time that such vendor engaged in
12 practices prohibited by applicable federal or State
13 law or regulation; or
14 (3) was an officer, or person owning, either
15 directly or indirectly, 5% or more of the shares of
16 stock or other evidences of ownership in a vendor at
17 the time such vendor engaged in practices prohibited
18 by applicable federal or State law or regulation; or
19 (4) was an owner of a sole proprietorship or
20 partner of a partnership which was a vendor at the time
21 such vendor engaged in practices prohibited by
22 applicable federal or State law or regulation; or
23 (h) The direct or indirect ownership of the vendor
24 (including the ownership of a vendor that is a sole
25 proprietorship, a partner's interest in a vendor that is a
26 partnership, or ownership of 5% or more of the shares of
SB3365 Enrolled - 512 - LRB104 18483 SSS 31925 b
1 stock or other evidences of ownership in a corporate
2 vendor) has been transferred by an individual who is
3 terminated, suspended, or excluded or barred from
4 participating as a vendor to the individual's spouse,
5 child, brother, sister, parent, grandparent, grandchild,
6 uncle, aunt, niece, nephew, cousin, or relative by
7 marriage.
8 (A-5) The Illinois Department may deny, suspend, or
9 terminate the eligibility of any person, firm, corporation,
10 association, agency, institution, or other legal entity to
11 participate as a vendor of goods or services to recipients
12 under the medical assistance program under Article V, or may
13 exclude any such person or entity from participation as such a
14 vendor, if, after reasonable notice and opportunity for a
15 hearing, the Illinois Department finds that the vendor; a
16 person with management responsibility for a vendor; an officer
17 or person owning, either directly or indirectly, 5% or more of
18 the shares of stock or other evidences of ownership in a
19 corporate vendor; an owner of a sole proprietorship that is a
20 vendor; or a partner in a partnership that is a vendor has been
21 convicted of an offense based on fraud or willful
22 misrepresentation related to any of the following:
23 (1) The medical assistance program under Article V of
24 this Code.
25 (2) A medical assistance or health care program in
26 another state.
SB3365 Enrolled - 513 - LRB104 18483 SSS 31925 b
1 (3) The Medicare program under Title XVIII of the
2 Social Security Act.
3 (4) The provision of health care services.
4 (5) A violation of this Code, as provided in Article
5 VIIIA, or another state or federal medical assistance
6 program or health care program.
7 (A-10) The Illinois Department may deny, suspend, or
8 terminate the eligibility of any person, firm, corporation,
9 association, agency, institution, or other legal entity to
10 participate as a vendor of goods or services to recipients
11 under the medical assistance program under Article V, or may
12 exclude any such person or entity from participation as such a
13 vendor, if, after reasonable notice and opportunity for a
14 hearing, the Illinois Department finds that (i) the vendor,
15 (ii) a person with management responsibility for a vendor,
16 (iii) an officer or person owning, either directly or
17 indirectly, 5% or more of the shares of stock or other
18 evidences of ownership in a corporate vendor, (iv) an owner of
19 a sole proprietorship that is a vendor, or (v) a partner in a
20 partnership that is a vendor has been convicted of an offense
21 related to any of the following:
22 (1) Murder.
23 (2) A Class X felony under the Criminal Code of 1961 or
24 the Criminal Code of 2012.
25 (3) Sexual misconduct that may subject recipients to
26 an undue risk of harm.
SB3365 Enrolled - 514 - LRB104 18483 SSS 31925 b
1 (4) A criminal offense that may subject recipients to
2 an undue risk of harm.
3 (5) A crime of fraud or dishonesty.
4 (6) A crime involving a controlled substance.
5 (7) A misdemeanor relating to fraud, theft,
6 embezzlement, breach of fiduciary responsibility, or other
7 financial misconduct related to a health care program.
8 (A-15) The Illinois Department may deny the eligibility of
9 any person, firm, corporation, association, agency,
10 institution, or other legal entity to participate as a vendor
11 of goods or services to recipients under the medical
12 assistance program under Article V if, after reasonable notice
13 and opportunity for a hearing, the Illinois Department finds:
14 (1) The applicant or any person with management
15 responsibility for the applicant; an officer or member of
16 the board of directors of an applicant; an entity owning
17 (directly or indirectly) 5% or more of the shares of stock
18 or other evidences of ownership in a corporate vendor
19 applicant; an owner of a sole proprietorship applicant; a
20 partner in a partnership applicant; or a technical or
21 other advisor to an applicant has a debt owed to the
22 Illinois Department, and no payment arrangements
23 acceptable to the Illinois Department have been made by
24 the applicant.
25 (2) The applicant or any person with management
26 responsibility for the applicant; an officer or member of
SB3365 Enrolled - 515 - LRB104 18483 SSS 31925 b
1 the board of directors of an applicant; an entity owning
2 (directly or indirectly) 5% or more of the shares of stock
3 or other evidences of ownership in a corporate vendor
4 applicant; an owner of a sole proprietorship applicant; a
5 partner in a partnership vendor applicant; or a technical
6 or other advisor to an applicant was (i) a person with
7 management responsibility, (ii) an officer or member of
8 the board of directors of an applicant, (iii) an entity
9 owning (directly or indirectly) 5% or more of the shares
10 of stock or other evidences of ownership in a corporate
11 vendor, (iv) an owner of a sole proprietorship, (v) a
12 partner in a partnership vendor, (vi) a technical or other
13 advisor to a vendor, during a period of time where the
14 conduct of that vendor resulted in a debt owed to the
15 Illinois Department, and no payment arrangements
16 acceptable to the Illinois Department have been made by
17 that vendor.
18 (3) There is a credible allegation of the use,
19 transfer, or lease of assets of any kind to an applicant
20 from a current or prior vendor who has a debt owed to the
21 Illinois Department, no payment arrangements acceptable to
22 the Illinois Department have been made by that vendor or
23 the vendor's alternate payee, and the applicant knows or
24 should have known of such debt.
25 (4) There is a credible allegation of a transfer of
26 management responsibilities, or direct or indirect
SB3365 Enrolled - 516 - LRB104 18483 SSS 31925 b
1 ownership, to an applicant from a current or prior vendor
2 who has a debt owed to the Illinois Department, and no
3 payment arrangements acceptable to the Illinois Department
4 have been made by that vendor or the vendor's alternate
5 payee, and the applicant knows or should have known of
6 such debt.
7 (5) There is a credible allegation of the use,
8 transfer, or lease of assets of any kind to an applicant
9 who is a spouse, child, brother, sister, parent,
10 grandparent, grandchild, uncle, aunt, niece, relative by
11 marriage, nephew, cousin, or relative of a current or
12 prior vendor who has a debt owed to the Illinois
13 Department and no payment arrangements acceptable to the
14 Illinois Department have been made.
15 (6) There is a credible allegation that the
16 applicant's previous affiliations with a provider of
17 medical services that has an uncollected debt, a provider
18 that has been or is subject to a payment suspension under a
19 federal health care program, or a provider that has been
20 previously excluded from participation in the medical
21 assistance program, poses a risk of fraud, waste, or abuse
22 to the Illinois Department.
23 As used in this subsection, "credible allegation" is
24 defined to include an allegation from any source, including,
25 but not limited to, fraud hotline complaints, claims data
26 mining, patterns identified through provider audits, civil
SB3365 Enrolled - 517 - LRB104 18483 SSS 31925 b
1 actions filed under the Illinois False Claims Act, and law
2 enforcement investigations. An allegation is considered to be
3 credible when it has indicia of reliability.
4 (B) The Illinois Department shall deny, suspend or
5 terminate the eligibility of any person, firm, corporation,
6 association, agency, institution or other legal entity to
7 participate as a vendor of goods or services to recipients
8 under the medical assistance program under Article V, or may
9 exclude any such person or entity from participation as such a
10 vendor:
11 (1) immediately, if such vendor is not properly
12 licensed, certified, or authorized;
13 (2) within 30 days of the date when such vendor's
14 professional license, certification or other authorization
15 has been refused renewal, restricted, revoked, suspended,
16 or otherwise terminated; or
17 (3) if such vendor has been convicted of a violation
18 of this Code, as provided in Article VIIIA.
19 (C) Upon termination, suspension, or exclusion of a vendor
20 of goods or services from participation in the medical
21 assistance program authorized by this Article, a person with
22 management responsibility for such vendor during the time of
23 any conduct which served as the basis for that vendor's
24 termination, suspension, or exclusion is barred from
25 participation in the medical assistance program.
26 Upon termination, suspension, or exclusion of a corporate
SB3365 Enrolled - 518 - LRB104 18483 SSS 31925 b
1 vendor, the officers and persons owning, directly or
2 indirectly, 5% or more of the shares of stock or other
3 evidences of ownership in the vendor during the time of any
4 conduct which served as the basis for that vendor's
5 termination, suspension, or exclusion are barred from
6 participation in the medical assistance program. A person who
7 owns, directly or indirectly, 5% or more of the shares of stock
8 or other evidences of ownership in a terminated, suspended, or
9 excluded vendor may not transfer his or her ownership interest
10 in that vendor to his or her spouse, child, brother, sister,
11 parent, grandparent, grandchild, uncle, aunt, niece, nephew,
12 cousin, or relative by marriage.
13 Upon termination, suspension, or exclusion of a sole
14 proprietorship or partnership, the owner or partners during
15 the time of any conduct which served as the basis for that
16 vendor's termination, suspension, or exclusion are barred from
17 participation in the medical assistance program. The owner of
18 a terminated, suspended, or excluded vendor that is a sole
19 proprietorship, and a partner in a terminated, suspended, or
20 excluded vendor that is a partnership, may not transfer his or
21 her ownership or partnership interest in that vendor to his or
22 her spouse, child, brother, sister, parent, grandparent,
23 grandchild, uncle, aunt, niece, nephew, cousin, or relative by
24 marriage.
25 A person who owns, directly or indirectly, 5% or more of
26 the shares of stock or other evidences of ownership in a
SB3365 Enrolled - 519 - LRB104 18483 SSS 31925 b
1 corporate or limited liability company vendor who owes a debt
2 to the Department, if that vendor has not made payment
3 arrangements acceptable to the Department, shall not transfer
4 his or her ownership interest in that vendor, or vendor assets
5 of any kind, to his or her spouse, child, brother, sister,
6 parent, grandparent, grandchild, uncle, aunt, niece, nephew,
7 cousin, or relative by marriage.
8 Rules adopted by the Illinois Department to implement
9 these provisions shall specifically include a definition of
10 the term "management responsibility" as used in this Section.
11 Such definition shall include, but not be limited to, typical
12 job titles, and duties and descriptions which will be
13 considered as within the definition of individuals with
14 management responsibility for a provider.
15 A vendor or a prior vendor who has been terminated,
16 excluded, or suspended from the medical assistance program, or
17 from another state or federal medical assistance or health
18 care program, and any individual currently or previously
19 barred from the medical assistance program, or from another
20 state or federal medical assistance or health care program, as
21 a result of being an officer or a person owning, directly or
22 indirectly, 5% or more of the shares of stock or other
23 evidences of ownership in a corporate or limited liability
24 company vendor during the time of any conduct which served as
25 the basis for that vendor's termination, suspension, or
26 exclusion, may be required to post a surety bond as part of a
SB3365 Enrolled - 520 - LRB104 18483 SSS 31925 b
1 condition of enrollment or participation in the medical
2 assistance program. The Illinois Department shall establish,
3 by rule, the criteria and requirements for determining when a
4 surety bond must be posted and the value of the bond.
5 A vendor or a prior vendor who has a debt owed to the
6 Illinois Department and any individual currently or previously
7 barred from the medical assistance program, or from another
8 state or federal medical assistance or health care program, as
9 a result of being an officer or a person owning, directly or
10 indirectly, 5% or more of the shares of stock or other
11 evidences of ownership in that corporate or limited liability
12 company vendor during the time of any conduct which served as
13 the basis for the debt, may be required to post a surety bond
14 as part of a condition of enrollment or participation in the
15 medical assistance program. The Illinois Department shall
16 establish, by rule, the criteria and requirements for
17 determining when a surety bond must be posted and the value of
18 the bond.
19 (D) If a vendor has been suspended from the medical
20 assistance program under Article V of the Code, the Director
21 may require that such vendor correct any deficiencies which
22 served as the basis for the suspension. The Director shall
23 specify in the suspension order a specific period of time,
24 which shall not exceed one year from the date of the order,
25 during which a suspended vendor shall not be eligible to
26 participate. At the conclusion of the period of suspension the
SB3365 Enrolled - 521 - LRB104 18483 SSS 31925 b
1 Director shall reinstate such vendor, unless he finds that
2 such vendor has not corrected deficiencies upon which the
3 suspension was based.
4 If a vendor has been terminated, suspended, or excluded
5 from the medical assistance program under Article V, such
6 vendor shall be barred from participation for at least one
7 year, except that if a vendor has been terminated, suspended,
8 or excluded based on a conviction of a violation of Article
9 VIIIA or a conviction of a felony based on fraud or a willful
10 misrepresentation related to (i) the medical assistance
11 program under Article V, (ii) a federal or another state's
12 medical assistance or health care program, or (iii) the
13 provision of health care services, then the vendor shall be
14 barred from participation for 5 years or for the length of the
15 vendor's sentence for that conviction, whichever is longer. At
16 the end of one year a vendor who has been terminated,
17 suspended, or excluded may apply for reinstatement to the
18 program. Upon proper application to be reinstated such vendor
19 may be deemed eligible by the Director providing that such
20 vendor meets the requirements for eligibility under this Code.
21 If such vendor is deemed not eligible for reinstatement, he
22 shall be barred from again applying for reinstatement for one
23 year from the date his application for reinstatement is
24 denied.
25 A vendor whose termination, suspension, or exclusion from
26 participation in the Illinois medical assistance program under
SB3365 Enrolled - 522 - LRB104 18483 SSS 31925 b
1 Article V was based solely on an action by a governmental
2 entity other than the Illinois Department may, upon
3 reinstatement by that governmental entity or upon reversal of
4 the termination, suspension, or exclusion, apply for
5 rescission of the termination, suspension, or exclusion from
6 participation in the Illinois medical assistance program. Upon
7 proper application for rescission, the vendor may be deemed
8 eligible by the Director if the vendor meets the requirements
9 for eligibility under this Code.
10 If a vendor has been terminated, suspended, or excluded
11 and reinstated to the medical assistance program under Article
12 V and the vendor is terminated, suspended, or excluded a
13 second or subsequent time from the medical assistance program,
14 the vendor shall be barred from participation for at least 2
15 years, except that if a vendor has been terminated, suspended,
16 or excluded a second time based on a conviction of a violation
17 of Article VIIIA or a conviction of a felony based on fraud or
18 a willful misrepresentation related to (i) the medical
19 assistance program under Article V, (ii) a federal or another
20 state's medical assistance or health care program, or (iii)
21 the provision of health care services, then the vendor shall
22 be barred from participation for life. At the end of 2 years, a
23 vendor who has been terminated, suspended, or excluded may
24 apply for reinstatement to the program. Upon application to be
25 reinstated, the vendor may be deemed eligible if the vendor
26 meets the requirements for eligibility under this Code. If the
SB3365 Enrolled - 523 - LRB104 18483 SSS 31925 b
1 vendor is deemed not eligible for reinstatement, the vendor
2 shall be barred from again applying for reinstatement for 2
3 years from the date the vendor's application for reinstatement
4 is denied.
5 (E) The Illinois Department may recover money improperly
6 or erroneously paid, or overpayments, either by setoff,
7 crediting against future billings or by requiring direct
8 repayment to the Illinois Department. The Illinois Department
9 may suspend or deny payment, in whole or in part, if such
10 payment would be improper or erroneous or would otherwise
11 result in overpayment.
12 (1) Payments may be suspended, denied, or recovered
13 from a vendor or alternate payee: (i) for services
14 rendered in violation of the Illinois Department's
15 provider notices, statutes, rules, and regulations; (ii)
16 for services rendered in violation of the terms and
17 conditions prescribed by the Illinois Department in its
18 vendor agreement; (iii) for any vendor who fails to grant
19 the Office of Inspector General timely access to full and
20 complete records, including, but not limited to, records
21 relating to recipients under the medical assistance
22 program for the most recent 6 years, in accordance with
23 Section 140.28 of Title 89 of the Illinois Administrative
24 Code, and other information for the purpose of audits,
25 investigations, or other program integrity functions,
26 after reasonable written request by the Inspector General;
SB3365 Enrolled - 524 - LRB104 18483 SSS 31925 b
1 this subsection (E) does not require vendors to make
2 available the medical records of patients for whom
3 services are not reimbursed under this Code or to provide
4 access to medical records more than 6 years old; (iv) when
5 the vendor has knowingly made, or caused to be made, any
6 false statement or representation of a material fact in
7 connection with the administration of the medical
8 assistance program; or (v) when the vendor previously
9 rendered services while terminated, suspended, or excluded
10 from participation in the medical assistance program or
11 while terminated or excluded from participation in another
12 state or federal medical assistance or health care
13 program.
14 (2) Notwithstanding any other provision of law, if a
15 vendor has the same taxpayer identification number
16 (assigned under Section 6109 of the Internal Revenue Code
17 of 1986) as is assigned to a vendor with past-due
18 financial obligations to the Illinois Department, the
19 Illinois Department may make any necessary adjustments to
20 payments to that vendor in order to satisfy any past-due
21 obligations, regardless of whether the vendor is assigned
22 a different billing number under the medical assistance
23 program.
24 (E-5) Civil monetary penalties.
25 (1) As used in this subsection (E-5):
26 (a) "Knowingly" means that a person, with respect
SB3365 Enrolled - 525 - LRB104 18483 SSS 31925 b
1 to information: (i) has actual knowledge of the
2 information; (ii) acts in deliberate ignorance of the
3 truth or falsity of the information; or (iii) acts in
4 reckless disregard of the truth or falsity of the
5 information. No proof of specific intent to defraud is
6 required.
7 (b) "Overpayment" means any funds that a person
8 receives or retains from the medical assistance
9 program to which the person, after applicable
10 reconciliation, is not entitled under this Code.
11 (c) "Remuneration" means the offer or transfer of
12 items or services for free or for other than fair
13 market value by a person; however, remuneration does
14 not include items or services of a nominal value of no
15 more than $10 per item or service, or $50 in the
16 aggregate on an annual basis, or any other offer or
17 transfer of items or services as determined by the
18 Department.
19 (d) "Should know" means that a person, with
20 respect to information: (i) acts in deliberate
21 ignorance of the truth or falsity of the information;
22 or (ii) acts in reckless disregard of the truth or
23 falsity of the information. No proof of specific
24 intent to defraud is required.
25 (2) Any person (including a vendor, provider,
26 organization, agency, or other entity, or an alternate
SB3365 Enrolled - 526 - LRB104 18483 SSS 31925 b
1 payee thereof, but excluding a recipient) who:
2 (a) knowingly presents or causes to be presented
3 to an officer, employee, or agent of the State, a claim
4 that the Department determines:
5 (i) is for a medical or other item or service
6 that the person knows or should know was not
7 provided as claimed, including any person who
8 engages in a pattern or practice of presenting or
9 causing to be presented a claim for an item or
10 service that is based on a code that the person
11 knows or should know will result in a greater
12 payment to the person than the code the person
13 knows or should know is applicable to the item or
14 service actually provided;
15 (ii) is for a medical or other item or service
16 and the person knows or should know that the claim
17 is false or fraudulent;
18 (iii) is presented for a vendor physician's
19 service, or an item or service incident to a
20 vendor physician's service, by a person who knows
21 or should know that the individual who furnished,
22 or supervised the furnishing of, the service:
23 (AA) was not licensed as a physician;
24 (BB) was licensed as a physician but such
25 license had been obtained through a
26 misrepresentation of material fact (including
SB3365 Enrolled - 527 - LRB104 18483 SSS 31925 b
1 cheating on an examination required for
2 licensing); or
3 (CC) represented to the patient at the
4 time the service was furnished that the
5 physician was certified in a medical specialty
6 by a medical specialty board, when the
7 individual was not so certified;
8 (iv) is for a medical or other item or service
9 furnished during a period in which the person was
10 excluded from the medical assistance program or a
11 federal or state health care program under which
12 the claim was made pursuant to applicable law; or
13 (v) is for a pattern of medical or other items
14 or services that a person knows or should know are
15 not medically necessary;
16 (b) knowingly presents or causes to be presented
17 to any person a request for payment which is in
18 violation of the conditions for receipt of vendor
19 payments under the medical assistance program under
20 Section 11-13 of this Code;
21 (c) knowingly gives or causes to be given to any
22 person, with respect to medical assistance program
23 coverage of inpatient hospital services, information
24 that he or she knows or should know is false or
25 misleading, and that could reasonably be expected to
26 influence the decision when to discharge such person
SB3365 Enrolled - 528 - LRB104 18483 SSS 31925 b
1 or other individual from the hospital;
2 (d) in the case of a person who is not an
3 organization, agency, or other entity, is excluded
4 from participating in the medical assistance program
5 or a federal or state health care program and who, at
6 the time of a violation of this subsection (E-5):
7 (i) retains a direct or indirect ownership or
8 control interest in an entity that is
9 participating in the medical assistance program or
10 a federal or state health care program, and who
11 knows or should know of the action constituting
12 the basis for the exclusion; or
13 (ii) is an officer or managing employee of
14 such an entity;
15 (e) offers or transfers remuneration to any
16 individual eligible for benefits under the medical
17 assistance program that such person knows or should
18 know is likely to influence such individual to order
19 or receive from a particular vendor, provider,
20 practitioner, or supplier any item or service for
21 which payment may be made, in whole or in part, under
22 the medical assistance program;
23 (f) arranges or contracts (by employment or
24 otherwise) with an individual or entity that the
25 person knows or should know is excluded from
26 participation in the medical assistance program or a
SB3365 Enrolled - 529 - LRB104 18483 SSS 31925 b
1 federal or state health care program, for the
2 provision of items or services for which payment may
3 be made under such a program;
4 (g) commits an act described in subsection (b) or
5 (c) of Section 8A-3;
6 (h) knowingly makes, uses, or causes to be made or
7 used, a false record or statement material to a false
8 or fraudulent claim for payment for items and services
9 furnished under the medical assistance program;
10 (i) fails to grant timely access, upon reasonable
11 request (as defined by the Department by rule), to the
12 Inspector General, for the purpose of audits,
13 investigations, evaluations, or other statutory
14 functions of the Inspector General of the Department;
15 (j) orders or prescribes a medical or other item
16 or service during a period in which the person was
17 excluded from the medical assistance program or a
18 federal or state health care program, in the case
19 where the person knows or should know that a claim for
20 such medical or other item or service will be made
21 under such a program;
22 (k) knowingly makes or causes to be made any false
23 statement, omission, or misrepresentation of a
24 material fact in any application, bid, or contract to
25 participate or enroll as a vendor or provider of
26 services or a supplier under the medical assistance
SB3365 Enrolled - 530 - LRB104 18483 SSS 31925 b
1 program;
2 (l) knows of an overpayment and does not report
3 and return the overpayment to the Department in
4 accordance with paragraph (6);
5 shall be subject, in addition to any other penalties that
6 may be prescribed by law, to a civil money penalty of not
7 more than $10,000 for each item or service (or, in cases
8 under subparagraph (c), $15,000 for each individual with
9 respect to whom false or misleading information was given;
10 in cases under subparagraph (d), $10,000 for each day the
11 prohibited relationship occurs; in cases under
12 subparagraph (g), $50,000 for each such act; in cases
13 under subparagraph (h), $50,000 for each false record or
14 statement; in cases under subparagraph (i), $15,000 for
15 each day of the failure described in such subparagraph; or
16 in cases under subparagraph (k), $50,000 for each false
17 statement, omission, or misrepresentation of a material
18 fact). In addition, such a person shall be subject to an
19 assessment of not more than 3 times the amount claimed for
20 each such item or service in lieu of damages sustained by
21 the State because of such claim (or, in cases under
22 subparagraph (g), damages of not more than 3 times the
23 total amount of remuneration offered, paid, solicited, or
24 received, without regard to whether a portion of such
25 remuneration was offered, paid, solicited, or received for
26 a lawful purpose; or in cases under subparagraph (k), an
SB3365 Enrolled - 531 - LRB104 18483 SSS 31925 b
1 assessment of not more than 3 times the total amount
2 claimed for each item or service for which payment was
3 made based upon the application, bid, or contract
4 containing the false statement, omission, or
5 misrepresentation of a material fact).
6 (3) In addition, the Director or his or her designee
7 may make a determination in the same proceeding to
8 exclude, terminate, suspend, or bar the person from
9 participation in the medical assistance program.
10 (4) The Illinois Department may seek the civil
11 monetary penalties and exclusion, termination, suspension,
12 or barment identified in this subsection (E-5). Prior to
13 the imposition of any penalties or sanctions, the affected
14 person shall be afforded an opportunity for a hearing
15 after reasonable notice. The Department shall establish
16 hearing procedures by rule.
17 (5) Any final order, decision, or other determination
18 made, issued, or executed by the Director under the
19 provisions of this subsection (E-5), whereby a person is
20 aggrieved, shall be subject to review in accordance with
21 the provisions of the Administrative Review Law, and the
22 rules adopted pursuant thereto, which shall apply to and
23 govern all proceedings for the judicial review of final
24 administrative decisions of the Director.
25 (6)(a) If a person has received an overpayment, the
26 person shall:
SB3365 Enrolled - 532 - LRB104 18483 SSS 31925 b
1 (i) report and return the overpayment to the
2 Department at the correct address; and
3 (ii) notify the Department in writing of the
4 reason for the overpayment.
5 (b) An overpayment must be reported and returned under
6 subparagraph (a) by the later of:
7 (i) the date which is 60 days after the date on
8 which the overpayment was identified; or
9 (ii) the date any corresponding cost report is
10 due, if applicable.
11 (E-10) A vendor who disputes an overpayment identified as
12 part of a Department audit shall utilize the Department's
13 self-referral disclosure protocol as set forth under this Code
14 to identify, investigate, and return to the Department any
15 undisputed audit overpayment amount. Unless the disputed
16 overpayment amount is subject to a fraud payment suspension,
17 or involves a termination sanction, the Department shall defer
18 the recovery of the disputed overpayment amount up to one year
19 after the date of the Department's final audit determination,
20 or earlier, or as required by State or federal law. If the
21 administrative hearing extends beyond one year, and such delay
22 was not caused by the request of the vendor, then the
23 Department shall not recover the disputed overpayment amount
24 until the date of the final administrative decision. If a
25 final administrative decision establishes that the disputed
26 overpayment amount is owed to the Department, then the amount
SB3365 Enrolled - 533 - LRB104 18483 SSS 31925 b
1 shall be immediately due to the Department. The Department
2 shall be entitled to recover interest from the vendor on the
3 overpayment amount from the date of the overpayment through
4 the date the vendor returns the overpayment to the Department
5 at a rate not to exceed the Wall Street Journal Prime Rate, as
6 published from time to time, but not to exceed 5%. Any interest
7 billed by the Department shall be due immediately upon receipt
8 of the Department's billing statement.
9 (F) The Illinois Department may withhold payments to any
10 vendor or alternate payee prior to or during the pendency of
11 any audit or proceeding under this Section, and through the
12 pendency of any administrative appeal or administrative review
13 by any court proceeding. The Illinois Department shall state
14 by rule with as much specificity as practicable the conditions
15 under which payments will not be withheld under this Section.
16 Payments may be denied for bills submitted with service dates
17 occurring during the pendency of a proceeding, after a final
18 decision has been rendered, or after the conclusion of any
19 administrative appeal, where the final administrative decision
20 is to terminate, exclude, or suspend eligibility to
21 participate in the medical assistance program. The Illinois
22 Department shall state by rule with as much specificity as
23 practicable the conditions under which payments will not be
24 denied for such bills. The Illinois Department shall state by
25 rule a process and criteria by which a vendor or alternate
26 payee may request full or partial release of payments withheld
SB3365 Enrolled - 534 - LRB104 18483 SSS 31925 b
1 under this subsection. The Department must complete a
2 proceeding under this Section in a timely manner.
3 Notwithstanding recovery allowed under subsection (E) or
4 this subsection (F), the Illinois Department may withhold
5 payments to any vendor or alternate payee who is not properly
6 licensed, certified, or in compliance with State or federal
7 agency regulations. Payments may be denied for bills submitted
8 with service dates occurring during the period of time that a
9 vendor is not properly licensed, certified, or in compliance
10 with State or federal regulations. Facilities licensed under
11 the Nursing Home Care Act shall have payments denied or
12 withheld pursuant to subsection (I) of this Section.
13 (F-5) The Illinois Department may temporarily withhold
14 payments to a vendor or alternate payee if any of the following
15 individuals have been indicted or otherwise charged under a
16 law of the United States or this or any other state with an
17 offense that is based on alleged fraud or willful
18 misrepresentation on the part of the individual related to (i)
19 the medical assistance program under Article V of this Code,
20 (ii) a federal or another state's medical assistance or health
21 care program, or (iii) the provision of health care services:
22 (1) If the vendor or alternate payee is a corporation:
23 an officer of the corporation or an individual who owns,
24 either directly or indirectly, 5% or more of the shares of
25 stock or other evidence of ownership of the corporation.
26 (2) If the vendor is a sole proprietorship: the owner
SB3365 Enrolled - 535 - LRB104 18483 SSS 31925 b
1 of the sole proprietorship.
2 (3) If the vendor or alternate payee is a partnership:
3 a partner in the partnership.
4 (4) If the vendor or alternate payee is any other
5 business entity authorized by law to transact business in
6 this State: an officer of the entity or an individual who
7 owns, either directly or indirectly, 5% or more of the
8 evidences of ownership of the entity.
9 If the Illinois Department withholds payments to a vendor
10 or alternate payee under this subsection, the Department shall
11 not release those payments to the vendor or alternate payee
12 while any criminal proceeding related to the indictment or
13 charge is pending unless the Department determines that there
14 is good cause to release the payments before completion of the
15 proceeding. If the indictment or charge results in the
16 individual's conviction, the Illinois Department shall retain
17 all withheld payments, which shall be considered forfeited to
18 the Department. If the indictment or charge does not result in
19 the individual's conviction, the Illinois Department shall
20 release to the vendor or alternate payee all withheld
21 payments.
22 (F-10) If the Illinois Department establishes that the
23 vendor or alternate payee owes a debt to the Illinois
24 Department, and the vendor or alternate payee subsequently
25 fails to pay or make satisfactory payment arrangements with
26 the Illinois Department for the debt owed, the Illinois
SB3365 Enrolled - 536 - LRB104 18483 SSS 31925 b
1 Department may seek all remedies available under the law of
2 this State to recover the debt, including, but not limited to,
3 wage garnishment or the filing of claims or liens against the
4 vendor or alternate payee.
5 (F-15) Enforcement of judgment.
6 (1) Any fine, recovery amount, other sanction, or
7 costs imposed, or part of any fine, recovery amount, other
8 sanction, or cost imposed, remaining unpaid after the
9 exhaustion of or the failure to exhaust judicial review
10 procedures under the Illinois Administrative Review Law is
11 a debt due and owing the State and may be collected using
12 all remedies available under the law.
13 (2) After expiration of the period in which judicial
14 review under the Illinois Administrative Review Law may be
15 sought for a final administrative decision, unless stayed
16 by a court of competent jurisdiction, the findings,
17 decision, and order of the Director may be enforced in the
18 same manner as a judgment entered by a court of competent
19 jurisdiction.
20 (3) In any case in which any person or entity has
21 failed to comply with a judgment ordering or imposing any
22 fine or other sanction, any expenses incurred by the
23 Illinois Department to enforce the judgment, including,
24 but not limited to, attorney's fees, court costs, and
25 costs related to property demolition or foreclosure, after
26 they are fixed by a court of competent jurisdiction or the
SB3365 Enrolled - 537 - LRB104 18483 SSS 31925 b
1 Director, shall be a debt due and owing the State and may
2 be collected in accordance with applicable law. Prior to
3 any expenses being fixed by a final administrative
4 decision pursuant to this subsection (F-15), the Illinois
5 Department shall provide notice to the individual or
6 entity that states that the individual or entity shall
7 appear at a hearing before the administrative hearing
8 officer to determine whether the individual or entity has
9 failed to comply with the judgment. The notice shall set
10 the date for such a hearing, which shall not be less than 7
11 days from the date that notice is served. If notice is
12 served by mail, the 7-day period shall begin to run on the
13 date that the notice was deposited in the mail.
14 (4) Upon being recorded in the manner required by
15 Article XII of the Code of Civil Procedure or by the
16 Uniform Commercial Code, a lien shall be imposed on the
17 real estate or personal estate, or both, of the individual
18 or entity in the amount of any debt due and owing the State
19 under this Section. The lien may be enforced in the same
20 manner as a judgment of a court of competent jurisdiction.
21 A lien shall attach to all property and assets of such
22 person, firm, corporation, association, agency,
23 institution, or other legal entity until the judgment is
24 satisfied.
25 (5) The Director may set aside any judgment entered by
26 default and set a new hearing date upon a petition filed at
SB3365 Enrolled - 538 - LRB104 18483 SSS 31925 b
1 any time (i) if the petitioner's failure to appear at the
2 hearing was for good cause, or (ii) if the petitioner
3 established that the Department did not provide proper
4 service of process. If any judgment is set aside pursuant
5 to this paragraph (5), the hearing officer shall have
6 authority to enter an order extinguishing any lien which
7 has been recorded for any debt due and owing the Illinois
8 Department as a result of the vacated default judgment.
9 (G) The provisions of the Administrative Review Law, as
10 now or hereafter amended, and the rules adopted pursuant
11 thereto, shall apply to and govern all proceedings for the
12 judicial review of final administrative decisions of the
13 Illinois Department under this Section. The term
14 "administrative decision" is defined as in Section 3-101 of
15 the Code of Civil Procedure.
16 (G-5) Vendors who pose a risk of fraud, waste, abuse, or
17 harm.
18 (1) Notwithstanding any other provision in this
19 Section, the Department may terminate, suspend, or exclude
20 vendors who pose a risk of fraud, waste, abuse, or harm
21 from participation in the medical assistance program prior
22 to an evidentiary hearing but after reasonable notice and
23 opportunity to respond as established by the Department by
24 rule.
25 (2) Vendors who pose a risk of fraud, waste, abuse, or
26 harm shall submit to a fingerprint-based criminal
SB3365 Enrolled - 539 - LRB104 18483 SSS 31925 b
1 background check on current and future information
2 available in the State system and current information
3 available through the Federal Bureau of Investigation's
4 system by submitting all necessary fees and information in
5 the form and manner prescribed by the Illinois State
6 Police. The following individuals shall be subject to the
7 check:
8 (A) In the case of a vendor that is a corporation,
9 every shareholder who owns, directly or indirectly, 5%
10 or more of the outstanding shares of the corporation.
11 (B) In the case of a vendor that is a partnership,
12 every partner.
13 (C) In the case of a vendor that is a sole
14 proprietorship, the sole proprietor.
15 (D) Each officer or manager of the vendor.
16 Each such vendor shall be responsible for payment of
17 the cost of the criminal background check.
18 (3) Vendors who pose a risk of fraud, waste, abuse, or
19 harm may be required to post a surety bond. The Department
20 shall establish, by rule, the criteria and requirements
21 for determining when a surety bond must be posted and the
22 value of the bond.
23 (4) The Department, or its agents, may refuse to
24 accept requests for authorization from specific vendors
25 who pose a risk of fraud, waste, abuse, or harm, including
26 prior-approval and post-approval requests, if:
SB3365 Enrolled - 540 - LRB104 18483 SSS 31925 b
1 (A) the Department has initiated a notice of
2 termination, suspension, or exclusion of the vendor
3 from participation in the medical assistance program;
4 or
5 (B) the Department has issued notification of its
6 withholding of payments pursuant to subsection (F-5)
7 of this Section; or
8 (C) the Department has issued a notification of
9 its withholding of payments due to reliable evidence
10 of fraud or willful misrepresentation pending
11 investigation.
12 (5) As used in this subsection, the following terms
13 are defined as follows:
14 (A) "Fraud" means an intentional deception or
15 misrepresentation made by a person with the knowledge
16 that the deception could result in some unauthorized
17 benefit to himself or herself or some other person. It
18 includes any act that constitutes fraud under
19 applicable federal or State law.
20 (B) "Abuse" means provider practices that are
21 inconsistent with sound fiscal, business, or medical
22 practices and that result in an unnecessary cost to
23 the medical assistance program or in reimbursement for
24 services that are not medically necessary or that fail
25 to meet professionally recognized standards for health
26 care. It also includes recipient practices that result
SB3365 Enrolled - 541 - LRB104 18483 SSS 31925 b
1 in unnecessary cost to the medical assistance program.
2 Abuse does not include diagnostic or therapeutic
3 measures conducted primarily as a safeguard against
4 possible vendor liability.
5 (C) "Waste" means the unintentional misuse of
6 medical assistance resources, resulting in unnecessary
7 cost to the medical assistance program. Waste does not
8 include diagnostic or therapeutic measures conducted
9 primarily as a safeguard against possible vendor
10 liability.
11 (D) "Harm" means physical, mental, or monetary
12 damage to recipients or to the medical assistance
13 program.
14 (G-6) The Illinois Department, upon making a determination
15 based upon information in the possession of the Illinois
16 Department that continuation of participation in the medical
17 assistance program by a vendor would constitute an immediate
18 danger to the public, may immediately suspend such vendor's
19 participation in the medical assistance program without a
20 hearing. In instances in which the Illinois Department
21 immediately suspends the medical assistance program
22 participation of a vendor under this Section, a hearing upon
23 the vendor's participation must be convened by the Illinois
24 Department within 15 days after such suspension and completed
25 without appreciable delay. Such hearing shall be held to
26 determine whether to recommend to the Director that the
SB3365 Enrolled - 542 - LRB104 18483 SSS 31925 b
1 vendor's medical assistance program participation be denied,
2 terminated, suspended, placed on provisional status, or
3 reinstated. In the hearing, any evidence relevant to the
4 vendor constituting an immediate danger to the public may be
5 introduced against such vendor; provided, however, that the
6 vendor, or his or her counsel, shall have the opportunity to
7 discredit, impeach, and submit evidence rebutting such
8 evidence.
9 (H) Nothing contained in this Code shall in any way limit
10 or otherwise impair the authority or power of any State agency
11 responsible for licensing of vendors.
12 (I) Based on a finding of noncompliance on the part of a
13 nursing home with any requirement for certification under
14 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
15 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
16 Department may impose one or more of the following remedies
17 after notice to the facility:
18 (1) Termination of the provider agreement.
19 (2) Temporary management.
20 (3) Denial of payment for new admissions.
21 (4) Civil money penalties.
22 (5) Closure of the facility in emergency situations or
23 transfer of residents, or both.
24 (6) State monitoring.
25 (7) Denial of all payments when the U.S. Department of
26 Health and Human Services has imposed this sanction.
SB3365 Enrolled - 543 - LRB104 18483 SSS 31925 b
1 The Illinois Department shall by rule establish criteria
2 governing continued payments to a nursing facility subsequent
3 to termination of the facility's provider agreement if, in the
4 sole discretion of the Illinois Department, circumstances
5 affecting the health, safety, and welfare of the facility's
6 residents require those continued payments. The Illinois
7 Department may condition those continued payments on the
8 appointment of temporary management, sale of the facility to
9 new owners or operators, or other arrangements that the
10 Illinois Department determines best serve the needs of the
11 facility's residents.
12 Except in the case of a facility that has a right to a
13 hearing on the finding of noncompliance before an agency of
14 the federal government, a facility may request a hearing
15 before a State agency on any finding of noncompliance within
16 60 days after the notice of the intent to impose a remedy.
17 Except in the case of civil money penalties, a request for a
18 hearing shall not delay imposition of the penalty. The choice
19 of remedies is not appealable at a hearing. The level of
20 noncompliance may be challenged only in the case of a civil
21 money penalty. The Illinois Department shall provide by rule
22 for the State agency that will conduct the evidentiary
23 hearings.
24 The Illinois Department may collect interest on unpaid
25 civil money penalties.
26 The Illinois Department may adopt all rules necessary to
SB3365 Enrolled - 544 - LRB104 18483 SSS 31925 b
1 implement this subsection (I).
2 (J) The Illinois Department, by rule, may permit
3 individual practitioners to designate that Department payments
4 that may be due the practitioner be made to an alternate payee
5 or alternate payees.
6 (a) Such alternate payee or alternate payees shall be
7 required to register as an alternate payee in the Medical
8 Assistance Program with the Illinois Department.
9 (b) If a practitioner designates an alternate payee,
10 the alternate payee and practitioner shall be jointly and
11 severally liable to the Department for payments made to
12 the alternate payee. Pursuant to subsection (E) of this
13 Section, any Department action to suspend or deny payment
14 or recover money or overpayments from an alternate payee
15 shall be subject to an administrative hearing.
16 (c) Registration as an alternate payee or alternate
17 payees in the Illinois Medical Assistance Program shall be
18 conditional. At any time, the Illinois Department may deny
19 or cancel any alternate payee's registration in the
20 Illinois Medical Assistance Program without cause. Any
21 such denial or cancellation is not subject to an
22 administrative hearing.
23 (d) The Illinois Department may seek a revocation of
24 any alternate payee, and all owners, officers, and
25 individuals with management responsibility for such
26 alternate payee shall be permanently prohibited from
SB3365 Enrolled - 545 - LRB104 18483 SSS 31925 b
1 participating as an owner, an officer, or an individual
2 with management responsibility with an alternate payee in
3 the Illinois Medical Assistance Program, if after
4 reasonable notice and opportunity for a hearing the
5 Illinois Department finds that:
6 (1) the alternate payee is not complying with the
7 Department's policy or rules and regulations, or with
8 the terms and conditions prescribed by the Illinois
9 Department in its alternate payee registration
10 agreement; or
11 (2) the alternate payee has failed to keep or make
12 available for inspection, audit, or copying, after
13 receiving a written request from the Illinois
14 Department, such records regarding payments claimed as
15 an alternate payee; or
16 (3) the alternate payee has failed to furnish any
17 information requested by the Illinois Department
18 regarding payments claimed as an alternate payee; or
19 (4) the alternate payee has knowingly made, or
20 caused to be made, any false statement or
21 representation of a material fact in connection with
22 the administration of the Illinois Medical Assistance
23 Program; or
24 (5) the alternate payee, a person with management
25 responsibility for an alternate payee, an officer or
26 person owning, either directly or indirectly, 5% or
SB3365 Enrolled - 546 - LRB104 18483 SSS 31925 b
1 more of the shares of stock or other evidences of
2 ownership in a corporate alternate payee, or a partner
3 in a partnership which is an alternate payee:
4 (a) was previously terminated, suspended, or
5 excluded from participation as a vendor in the
6 Illinois Medical Assistance Program, or was
7 previously revoked as an alternate payee in the
8 Illinois Medical Assistance Program, or was
9 terminated, suspended, or excluded from
10 participation as a vendor in a medical assistance
11 program in another state that is of the same kind
12 as the program of medical assistance provided
13 under Article V of this Code; or
14 (b) was a person with management
15 responsibility for a vendor previously terminated,
16 suspended, or excluded from participation as a
17 vendor in the Illinois Medical Assistance Program,
18 or was previously revoked as an alternate payee in
19 the Illinois Medical Assistance Program, or was
20 terminated, suspended, or excluded from
21 participation as a vendor in a medical assistance
22 program in another state that is of the same kind
23 as the program of medical assistance provided
24 under Article V of this Code, during the time of
25 conduct which was the basis for that vendor's
26 termination, suspension, or exclusion or alternate
SB3365 Enrolled - 547 - LRB104 18483 SSS 31925 b
1 payee's revocation; or
2 (c) was an officer, or person owning, either
3 directly or indirectly, 5% or more of the shares
4 of stock or other evidences of ownership in a
5 corporate vendor previously terminated, suspended,
6 or excluded from participation as a vendor in the
7 Illinois Medical Assistance Program, or was
8 previously revoked as an alternate payee in the
9 Illinois Medical Assistance Program, or was
10 terminated, suspended, or excluded from
11 participation as a vendor in a medical assistance
12 program in another state that is of the same kind
13 as the program of medical assistance provided
14 under Article V of this Code, during the time of
15 conduct which was the basis for that vendor's
16 termination, suspension, or exclusion; or
17 (d) was an owner of a sole proprietorship or
18 partner in a partnership previously terminated,
19 suspended, or excluded from participation as a
20 vendor in the Illinois Medical Assistance Program,
21 or was previously revoked as an alternate payee in
22 the Illinois Medical Assistance Program, or was
23 terminated, suspended, or excluded from
24 participation as a vendor in a medical assistance
25 program in another state that is of the same kind
26 as the program of medical assistance provided
SB3365 Enrolled - 548 - LRB104 18483 SSS 31925 b
1 under Article V of this Code, during the time of
2 conduct which was the basis for that vendor's
3 termination, suspension, or exclusion or alternate
4 payee's revocation; or
5 (6) the alternate payee, a person with management
6 responsibility for an alternate payee, an officer or
7 person owning, either directly or indirectly, 5% or
8 more of the shares of stock or other evidences of
9 ownership in a corporate alternate payee, or a partner
10 in a partnership which is an alternate payee:
11 (a) has engaged in conduct prohibited by
12 applicable federal or State law or regulation
13 relating to the Illinois Medical Assistance
14 Program; or
15 (b) was a person with management
16 responsibility for a vendor or alternate payee at
17 the time that the vendor or alternate payee
18 engaged in practices prohibited by applicable
19 federal or State law or regulation relating to the
20 Illinois Medical Assistance Program; or
21 (c) was an officer, or person owning, either
22 directly or indirectly, 5% or more of the shares
23 of stock or other evidences of ownership in a
24 vendor or alternate payee at the time such vendor
25 or alternate payee engaged in practices prohibited
26 by applicable federal or State law or regulation
SB3365 Enrolled - 549 - LRB104 18483 SSS 31925 b
1 relating to the Illinois Medical Assistance
2 Program; or
3 (d) was an owner of a sole proprietorship or
4 partner in a partnership which was a vendor or
5 alternate payee at the time such vendor or
6 alternate payee engaged in practices prohibited by
7 applicable federal or State law or regulation
8 relating to the Illinois Medical Assistance
9 Program; or
10 (7) the direct or indirect ownership of the vendor
11 or alternate payee (including the ownership of a
12 vendor or alternate payee that is a partner's interest
13 in a vendor or alternate payee, or ownership of 5% or
14 more of the shares of stock or other evidences of
15 ownership in a corporate vendor or alternate payee)
16 has been transferred by an individual who is
17 terminated, suspended, or excluded or barred from
18 participating as a vendor or is prohibited or revoked
19 as an alternate payee to the individual's spouse,
20 child, brother, sister, parent, grandparent,
21 grandchild, uncle, aunt, niece, nephew, cousin, or
22 relative by marriage.
23 (K) The Illinois Department of Healthcare and Family
24 Services may withhold payments, in whole or in part, to a
25 provider or alternate payee where there is credible evidence,
26 received from State or federal law enforcement or federal
SB3365 Enrolled - 550 - LRB104 18483 SSS 31925 b
1 oversight agencies or from the results of a preliminary
2 Department audit, that the circumstances giving rise to the
3 need for a withholding of payments may involve fraud or
4 willful misrepresentation under the Illinois Medical
5 Assistance program. The Department shall by rule define what
6 constitutes "credible" evidence for purposes of this
7 subsection. The Department may withhold payments without first
8 notifying the provider or alternate payee of its intention to
9 withhold such payments. A provider or alternate payee may
10 request a reconsideration of payment withholding, and the
11 Department must grant such a request. The Department shall
12 state by rule a process and criteria by which a provider or
13 alternate payee may request full or partial release of
14 payments withheld under this subsection. This request may be
15 made at any time after the Department first withholds such
16 payments.
17 (a) The Illinois Department must send notice of its
18 withholding of program payments within 5 days of taking
19 such action. The notice must set forth the general
20 allegations as to the nature of the withholding action,
21 but need not disclose any specific information concerning
22 its ongoing investigation. The notice must do all of the
23 following:
24 (1) State that payments are being withheld in
25 accordance with this subsection.
26 (2) State that the withholding is for a temporary
SB3365 Enrolled - 551 - LRB104 18483 SSS 31925 b
1 period, as stated in paragraph (b) of this subsection,
2 and cite the circumstances under which withholding
3 will be terminated.
4 (3) Specify, when appropriate, which type or types
5 of Medicaid claims withholding is effective.
6 (4) Inform the provider or alternate payee of the
7 right to submit written evidence for reconsideration
8 of the withholding by the Illinois Department.
9 (5) Inform the provider or alternate payee that a
10 written request may be made to the Illinois Department
11 for full or partial release of withheld payments and
12 that such requests may be made at any time after the
13 Department first withholds such payments.
14 (b) All withholding-of-payment actions under this
15 subsection shall be temporary and shall not continue after
16 any of the following:
17 (1) The Illinois Department or the prosecuting
18 authorities determine that there is insufficient
19 evidence of fraud or willful misrepresentation by the
20 provider or alternate payee.
21 (2) Legal proceedings related to the provider's or
22 alternate payee's alleged fraud, willful
23 misrepresentation, violations of this Act, or
24 violations of the Illinois Department's administrative
25 rules are completed.
26 (3) The withholding of payments for a period of 3
SB3365 Enrolled - 552 - LRB104 18483 SSS 31925 b
1 years.
2 (c) The Illinois Department may adopt all rules
3 necessary to implement this subsection (K).
4 (K-5) The Illinois Department may withhold payments, in
5 whole or in part, to a provider or alternate payee upon
6 initiation of an audit, quality of care review, investigation
7 when there is a credible allegation of fraud, or the provider
8 or alternate payee demonstrating a clear failure to cooperate
9 with the Illinois Department such that the circumstances give
10 rise to the need for a withholding of payments. As used in this
11 subsection, "credible allegation" is defined to include an
12 allegation from any source, including, but not limited to,
13 fraud hotline complaints, claims data mining, patterns
14 identified through provider audits, civil actions filed under
15 the Illinois False Claims Act, and law enforcement
16 investigations. An allegation is considered to be credible
17 when it has indicia of reliability. The Illinois Department
18 may withhold payments without first notifying the provider or
19 alternate payee of its intention to withhold such payments. A
20 provider or alternate payee may request a hearing or a
21 reconsideration of payment withholding, and the Illinois
22 Department must grant such a request. The Illinois Department
23 shall state by rule a process and criteria by which a provider
24 or alternate payee may request a hearing or a reconsideration
25 for the full or partial release of payments withheld under
26 this subsection. This request may be made at any time after the
SB3365 Enrolled - 553 - LRB104 18483 SSS 31925 b
1 Illinois Department first withholds such payments.
2 (a) The Illinois Department must send notice of its
3 withholding of program payments within 5 days of taking
4 such action. The notice must set forth the general
5 allegations as to the nature of the withholding action but
6 need not disclose any specific information concerning its
7 ongoing investigation. The notice must do all of the
8 following:
9 (1) State that payments are being withheld in
10 accordance with this subsection.
11 (2) State that the withholding is for a temporary
12 period, as stated in paragraph (b) of this subsection,
13 and cite the circumstances under which withholding
14 will be terminated.
15 (3) Specify, when appropriate, which type or types
16 of claims are withheld.
17 (4) Inform the provider or alternate payee of the
18 right to request a hearing or a reconsideration of the
19 withholding by the Illinois Department, including the
20 ability to submit written evidence.
21 (5) Inform the provider or alternate payee that a
22 written request may be made to the Illinois Department
23 for a hearing or a reconsideration for the full or
24 partial release of withheld payments and that such
25 requests may be made at any time after the Illinois
26 Department first withholds such payments.
SB3365 Enrolled - 554 - LRB104 18483 SSS 31925 b
1 (b) All withholding of payment actions under this
2 subsection shall be temporary and shall not continue after
3 any of the following:
4 (1) The Illinois Department determines that there
5 is insufficient evidence of fraud, or the provider or
6 alternate payee demonstrates clear cooperation with
7 the Illinois Department, as determined by the Illinois
8 Department, such that the circumstances do not give
9 rise to the need for withholding of payments; or
10 (2) The withholding of payments has lasted for a
11 period in excess of 3 years.
12 (c) The Illinois Department may adopt all rules
13 necessary to implement this subsection (K-5).
14 (L) The Illinois Department shall establish a protocol to
15 enable health care providers to disclose an actual or
16 potential violation of this Section pursuant to a
17 self-referral disclosure protocol, referred to in this
18 subsection as "the protocol". The protocol shall include
19 direction for health care providers on a specific person,
20 official, or office to whom such disclosures shall be made.
21 The Illinois Department shall post information on the protocol
22 on the Illinois Department's public website. The Illinois
23 Department may adopt rules necessary to implement this
24 subsection (L). In addition to other factors that the Illinois
25 Department finds appropriate, the Illinois Department may
26 consider a health care provider's timely use or failure to use
SB3365 Enrolled - 555 - LRB104 18483 SSS 31925 b
1 the protocol in considering the provider's failure to comply
2 with this Code.
3 (M) Notwithstanding any other provision of this Code, the
4 Illinois Department, at its discretion, may exempt an entity
5 licensed under the Nursing Home Care Act, the ID/DD Community
6 Care Act, or the MC/DD Act from the provisions of subsections
7 (A-15), (B), and (C) of this Section if the licensed entity is
8 in receivership.
9 (O) Enforcement of advance payment agreements. To the
10 extent not prohibited by federal or State law, and
11 notwithstanding any other provision of this Code, if a
12 provider fails to comply with the terms of an advance payment
13 agreement, the Department is authorized to collect any unpaid
14 advance balance through one or more of the following methods:
15 (1) Direct withholding of Department reimbursements.
16 The Department may withhold reimbursement or other amounts
17 otherwise payable by the Department to the provider,
18 including, but not limited to, fee-for-service claims
19 payments, supplemental payments, and any other amounts the
20 Department is obligated to pay the provider under the
21 medical assistance program, and apply such withheld
22 amounts as repayment of the unpaid advance.
23 (2) Managed care organizations remittance. If a
24 provider participates in a managed care program
25 administered by the Department, the Department may direct
26 the managed care organization to remit to the Department
SB3365 Enrolled - 556 - LRB104 18483 SSS 31925 b
1 amounts otherwise payable by the managed care organization
2 to the provider, and apply such remitted amounts as
3 repayment of the unpaid advance.
4 The requirements of this subsection may be waived by the
5 Department in instances when a nursing home provider has
6 entered into and remains in compliance with a renegotiated
7 advance payment agreement. A renegotiated advance payment
8 agreement must be entered into no later than 60 days after the
9 effective date of this amendatory Act of the 104th General
10 Assembly.
11 A nursing home must enter into a renegotiated advance
12 payment agreement with the Department that includes terms for
13 repayment of the total amount owed for all outstanding amounts
14 over a 12-month period, repaid in equal payment increments.
15 Payments shall begin within 30 days of the signed agreement
16 date.
17 Failure to remain in compliance with a renegotiated
18 advance payment agreement shall cause immediate termination of
19 such an agreement unless there is prior written consent from
20 the Department for a period of non-compliance.
21 Beginning September 1, 2026, the Department shall
22 immediately collect all overdue unpaid advance debts through
23 the collection methods authorized under this Section, unless a
24 renegotiated advance payment agreement has already been agreed
25 to.
26 (Source: P.A. 102-538, eff. 8-20-21.)
SB3365 Enrolled - 557 - LRB104 18483 SSS 31925 b
1 ARTICLE 265.
2 Section 265-5. The State Finance Act is amended by adding
3 Sections 5.1039 and 6z-149 as follows:
4 (30 ILCS 105/5.1039 new)
5 Sec. 5.1039. The Staffing Improvement and Long Term Care
6 Oversight Fund.
7 (30 ILCS 105/6z-149 new)
8 Sec. 6z-149. The Staffing Improvement and Long Term Care
9 Oversight Fund.
10 (a) The Staffing Improvement and Long Term Care Oversight
11 Fund is created as a special fund in the State treasury.
12 Interest earned by the Fund shall be credited to the Fund.
13 (b) Any moneys generated from penalties imposed for
14 non-compliance with minimum staffing standards under Section
15 3-202.05 of the Nursing Home Care Act shall be deposited into
16 the Fund. Any funds distributed and granted pursuant to this
17 Section shall be contingent on the Department's actual
18 collection of staffing fines under Section 3-202.02 of the
19 Nursing Home Care Act. Beginning in Fiscal Year 2027, funds
20 shall be distributed as follows:
21 (1) $1,000,000 shall be used in each State fiscal year
22 by the Department of Public Health to train surveyors for
SB3365 Enrolled - 558 - LRB104 18483 SSS 31925 b
1 administration of the Bureau of Long Term Care Training.
2 This funding shall not be used to used to replace any other
3 funding appropriated by the General Assembly for this
4 purpose.
5 (2) 15% of the funding shall be used by the of Public
6 Health to fund Nursing Home Care Act compliance efforts.
7 (3) $2,000,000 or 50% of the remainder of the moneys
8 deposited under this subsection after the allocations
9 under paragraphs (1) and (2) have been completed,
10 whichever is higher, shall be allocated in each State
11 fiscal year to be ordered transferred by the State
12 Comptroller and transferred by the State Treasurer from
13 the Staffing Improvement and Long Term Care Oversight Fund
14 to be used by the Department to support a Certified
15 Nursing Assistant Workforce Pipeline Program to recruit,
16 support, and train individuals to work as certified
17 nursing assistants at nursing facilities, with a focus on
18 facilities in disadvantaged communities, those serving
19 residents of color, and understaffed facilities. The
20 program shall be administered by a labor-management
21 organization acting on behalf of a partnership between
22 nursing facilities and a labor organization representing
23 nursing home workers. The labor-management organization
24 must demonstrate the ability to recruit, support, train,
25 and place individuals in careers in health care with a
26 specific focus on addressing staff shortages. Program
SB3365 Enrolled - 559 - LRB104 18483 SSS 31925 b
1 training and instruction must meet State and federal
2 education regulations and must provide a pathway for
3 participants to receive certification as nursing
4 assistants. Any funds distributed pursuant to this Section
5 shall be compliant with the Grant Accountability and
6 Transparency Act and its regulations, as applicable.
7 The program may provide supportive services to program
8 participants, including, but not limited to, mentoring and
9 a wraparound support stipend that would cover expenses
10 such as utilities, dependent care, and transportation.
11 (4) $2,000,000 shall be used in each State fiscal year
12 by the Department of Public Health to administer the
13 identified offenders and other safety activities.
14 (5) 40% of the remainder of the moneys deposited under
15 this subsection after the allocations under paragraphs
16 (1), (2), (3), and (4) have been completed shall, in each
17 fiscal year, be ordered transferred by the State
18 Comptroller and transferred by the State Treasurer from
19 the Staffing Improvement and Long Term Care Fund to the
20 State Board of Education Special Purposes Trust Fund to be
21 used by the State Board of Education to support the
22 allocation of formula grants for the purposes of
23 supporting programs and coursework that provide vocational
24 training of certified nursing assistants at the secondary
25 level of education, provided that the funds are allocated
26 for the purpose of increasing staffing in Illinois nursing
SB3365 Enrolled - 560 - LRB104 18483 SSS 31925 b
1 homes. Entities eligible for award include area career
2 centers and Education for Employment regional CTE systems,
3 as approved by rule of the State Board of Education. Each
4 eligible entity shall receive a formula grant based on
5 student enrollment, credential attainment, and employment.
6 The total appropriation that the State Board of Education
7 receives shall be divided into formula grants proportional
8 to each eligible entity's student participation,
9 credential attainment, and employment according to the
10 following: 50% shall be divided among all entities with
11 students enrolled in all health sciences pathways, 15%
12 shall be divided across all entities with students earning
13 CNA certificates, 20% shall be divided by each student
14 placed at elder care facilities for work-based learning in
15 the prior school year, and 15% shall be divided by the
16 total number of graduates from the prior fiscal year who
17 are employed at elder care facilities. Recipients will
18 provide mid-year and annual reports on templates provided
19 by rhe State Board of Education. Any entity receiving
20 funds under paragraph (3) is not eligible to receive
21 funding under this subsection.
22 (6) 40% of the remainder of the moneys deposited under
23 this subsection after the allocations under paragraphs
24 (1), (2), (3), and (4) have been completed shall, in each
25 fiscal year, be ordered transferred by the State
26 Comptroller and transferred by the State Treasurer from
SB3365 Enrolled - 561 - LRB104 18483 SSS 31925 b
1 the Staffing Improvement and Long Term Care Oversight Fund
2 to the Education Assistance Fund for the Long Term Care
3 Nursing Scholarship Program for scholarships to be awarded
4 to applicants pursuing or intending to pursue employment
5 as a nurse in a licensed nursing home in Illinois. The
6 Illinois Student Assistance Commission shall adopt
7 administrative rules governing the amount, criteria, and
8 award of scholarships to be awarded under this Section.
9 Section 265-10. The Nursing Home Care Act is amended by
10 changing Section 3-202.05 as follows:
11 (210 ILCS 45/3-202.05)
12 Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
13 thereafter.
14 (a) For the purpose of computing staff to resident ratios,
15 direct care staff shall include:
16 (1) registered nurses;
17 (2) licensed practical nurses;
18 (3) certified nurse assistants;
19 (4) psychiatric services rehabilitation aides;
20 (5) rehabilitation and therapy aides;
21 (6) psychiatric services rehabilitation coordinators;
22 (7) assistant directors of nursing;
23 (8) 50% of the Director of Nurses' time; and
24 (9) 30% of the Social Services Directors' time.
SB3365 Enrolled - 562 - LRB104 18483 SSS 31925 b
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.
SB3365 Enrolled - 563 - LRB104 18483 SSS 31925 b
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.
SB3365 Enrolled - 564 - LRB104 18483 SSS 31925 b
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
SB3365 Enrolled - 565 - LRB104 18483 SSS 31925 b
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
SB3365 Enrolled - 566 - LRB104 18483 SSS 31925 b
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
SB3365 Enrolled - 567 - LRB104 18483 SSS 31925 b
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
SB3365 Enrolled - 568 - LRB104 18483 SSS 31925 b
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 where there is no more than a 10% deviation from the
10 staffing requirements, in which case the facility shall not
11 receive a violation or penalty. The Department is granted
12 discretion to waive the violation and penalty when unforeseen
13 circumstances have occurred that resulted in call-offs of
14 scheduled staff. This provision shall be applied no more than
15 6 times per quarter. Nothing in this Section diminishes a
16 facility's right to appeal the imposition of a monetary
17 penalty. No facility may appeal a notice of noncompliance
18 issued during the revised implementation period. The changes
19 made to this subsection by this amendatory Act of the 104th
20 General Assembly in regard to nursing home staffing fines
21 shall apply to the July 1, 2025 fines based on data for the
22 quarter beginning January 1, 2025 through March 31, 2025 and
23 quarterly thereafter.
24 Moneys generated from the monetary penalties imposed on
25 facilities that are not in compliance with minimum staffing
26 standards under this subsection and rules adopted under this
SB3365 Enrolled - 569 - LRB104 18483 SSS 31925 b
1 subsection shall be deposited into the Staffing Improvement
2 and Long Term Care Oversight Fund and shall be used as provided
3 in Section 6z-149 of the State Finance Act.
4 (Source: P.A. 104-9, eff. 6-16-25.)
5 ARTICLE 800.
6 Section 800-95. No acceleration or delay. Where this Act
7 makes changes in a statute that is represented in this Act by
8 text that is not yet or no longer in effect (for example, a
9 Section represented by multiple versions), the use of that
10 text does not accelerate or delay the taking effect of (i) the
11 changes made by this Act or (ii) provisions derived from any
12 other Public Act.
13 ARTICLE 999.
14 Section 999-99. Effective date. This Act takes effect upon
15 becoming law, except that Section 257-10 of Article 257 and
16 Articles 2, 10, 15, and 225 take effect July 1, 2026, and
17 Article 6 takes effect January 1, 2027, and Article 65 takes
18 effect July 1, 2027.Every fact on this page links to its source, starting with the official bill record.