SB2840 EnrolledLRB097 15631 KTG 62714 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be referred to as the
5Save Medicaid Access and Resources Together (SMART) Act.
 
6    Section 5. Purpose. In order to address the significant
7spending and liability deficit in the medical assistance
8program budget of the Department of Healthcare and Family
9Services, the SMART Act hereby implements changes,
10improvements, and efficiencies to enhance Medicaid program
11integrity to prevent client and provider fraud; imposes
12controls on use of Medicaid services to prevent over-use or
13waste; expands cost-sharing by clients; redesigns the Medicaid
14healthcare delivery system; and makes rate adjustments and
15reductions to update rates or reflect budget realities.
 
16    Section 10. The Illinois Administrative Procedure Act is
17amended by changing Section 5-45 as follows:
 
18    (5 ILCS 100/5-45)  (from Ch. 127, par. 1005-45)
19    Sec. 5-45. Emergency rulemaking.
20    (a) "Emergency" means the existence of any situation that
21any agency finds reasonably constitutes a threat to the public

 

 

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1interest, safety, or welfare.
2    (b) If any agency finds that an emergency exists that
3requires adoption of a rule upon fewer days than is required by
4Section 5-40 and states in writing its reasons for that
5finding, the agency may adopt an emergency rule without prior
6notice or hearing upon filing a notice of emergency rulemaking
7with the Secretary of State under Section 5-70. The notice
8shall include the text of the emergency rule and shall be
9published in the Illinois Register. Consent orders or other
10court orders adopting settlements negotiated by an agency may
11be adopted under this Section. Subject to applicable
12constitutional or statutory provisions, an emergency rule
13becomes effective immediately upon filing under Section 5-65 or
14at a stated date less than 10 days thereafter. The agency's
15finding and a statement of the specific reasons for the finding
16shall be filed with the rule. The agency shall take reasonable
17and appropriate measures to make emergency rules known to the
18persons who may be affected by them.
19    (c) An emergency rule may be effective for a period of not
20longer than 150 days, but the agency's authority to adopt an
21identical rule under Section 5-40 is not precluded. No
22emergency rule may be adopted more than once in any 24 month
23period, except that this limitation on the number of emergency
24rules that may be adopted in a 24 month period does not apply
25to (i) emergency rules that make additions to and deletions
26from the Drug Manual under Section 5-5.16 of the Illinois

 

 

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1Public Aid Code or the generic drug formulary under Section
23.14 of the Illinois Food, Drug and Cosmetic Act, (ii)
3emergency rules adopted by the Pollution Control Board before
4July 1, 1997 to implement portions of the Livestock Management
5Facilities Act, (iii) emergency rules adopted by the Illinois
6Department of Public Health under subsections (a) through (i)
7of Section 2 of the Department of Public Health Act when
8necessary to protect the public's health, (iv) emergency rules
9adopted pursuant to subsection (n) of this Section, or (v)
10emergency rules adopted pursuant to subsection (o) of this
11Section. Two or more emergency rules having substantially the
12same purpose and effect shall be deemed to be a single rule for
13purposes of this Section.
14    (d) In order to provide for the expeditious and timely
15implementation of the State's fiscal year 1999 budget,
16emergency rules to implement any provision of Public Act 90-587
17or 90-588 or any other budget initiative for fiscal year 1999
18may be adopted in accordance with this Section by the agency
19charged with administering that provision or initiative,
20except that the 24-month limitation on the adoption of
21emergency rules and the provisions of Sections 5-115 and 5-125
22do not apply to rules adopted under this subsection (d). The
23adoption of emergency rules authorized by this subsection (d)
24shall be deemed to be necessary for the public interest,
25safety, and welfare.
26    (e) In order to provide for the expeditious and timely

 

 

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1implementation of the State's fiscal year 2000 budget,
2emergency rules to implement any provision of this amendatory
3Act of the 91st General Assembly or any other budget initiative
4for fiscal year 2000 may be adopted in accordance with this
5Section by the agency charged with administering that provision
6or initiative, except that the 24-month limitation on the
7adoption of emergency rules and the provisions of Sections
85-115 and 5-125 do not apply to rules adopted under this
9subsection (e). The adoption of emergency rules authorized by
10this subsection (e) shall be deemed to be necessary for the
11public interest, safety, and welfare.
12    (f) In order to provide for the expeditious and timely
13implementation of the State's fiscal year 2001 budget,
14emergency rules to implement any provision of this amendatory
15Act of the 91st General Assembly or any other budget initiative
16for fiscal year 2001 may be adopted in accordance with this
17Section by the agency charged with administering that provision
18or initiative, except that the 24-month limitation on the
19adoption of emergency rules and the provisions of Sections
205-115 and 5-125 do not apply to rules adopted under this
21subsection (f). The adoption of emergency rules authorized by
22this subsection (f) shall be deemed to be necessary for the
23public interest, safety, and welfare.
24    (g) In order to provide for the expeditious and timely
25implementation of the State's fiscal year 2002 budget,
26emergency rules to implement any provision of this amendatory

 

 

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1Act of the 92nd General Assembly or any other budget initiative
2for fiscal year 2002 may be adopted in accordance with this
3Section by the agency charged with administering that provision
4or initiative, except that the 24-month limitation on the
5adoption of emergency rules and the provisions of Sections
65-115 and 5-125 do not apply to rules adopted under this
7subsection (g). The adoption of emergency rules authorized by
8this subsection (g) shall be deemed to be necessary for the
9public interest, safety, and welfare.
10    (h) In order to provide for the expeditious and timely
11implementation of the State's fiscal year 2003 budget,
12emergency rules to implement any provision of this amendatory
13Act of the 92nd General Assembly or any other budget initiative
14for fiscal year 2003 may be adopted in accordance with this
15Section by the agency charged with administering that provision
16or initiative, except that the 24-month limitation on the
17adoption of emergency rules and the provisions of Sections
185-115 and 5-125 do not apply to rules adopted under this
19subsection (h). The adoption of emergency rules authorized by
20this subsection (h) shall be deemed to be necessary for the
21public interest, safety, and welfare.
22    (i) In order to provide for the expeditious and timely
23implementation of the State's fiscal year 2004 budget,
24emergency rules to implement any provision of this amendatory
25Act of the 93rd General Assembly or any other budget initiative
26for fiscal year 2004 may be adopted in accordance with this

 

 

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1Section by the agency charged with administering that provision
2or initiative, except that the 24-month limitation on the
3adoption of emergency rules and the provisions of Sections
45-115 and 5-125 do not apply to rules adopted under this
5subsection (i). The adoption of emergency rules authorized by
6this subsection (i) shall be deemed to be necessary for the
7public interest, safety, and welfare.
8    (j) In order to provide for the expeditious and timely
9implementation of the provisions of the State's fiscal year
102005 budget as provided under the Fiscal Year 2005 Budget
11Implementation (Human Services) Act, emergency rules to
12implement any provision of the Fiscal Year 2005 Budget
13Implementation (Human Services) Act may be adopted in
14accordance with this Section by the agency charged with
15administering that provision, except that the 24-month
16limitation on the adoption of emergency rules and the
17provisions of Sections 5-115 and 5-125 do not apply to rules
18adopted under this subsection (j). The Department of Public Aid
19may also adopt rules under this subsection (j) necessary to
20administer the Illinois Public Aid Code and the Children's
21Health Insurance Program Act. The adoption of emergency rules
22authorized by this subsection (j) shall be deemed to be
23necessary for the public interest, safety, and welfare.
24    (k) In order to provide for the expeditious and timely
25implementation of the provisions of the State's fiscal year
262006 budget, emergency rules to implement any provision of this

 

 

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1amendatory Act of the 94th General Assembly or any other budget
2initiative for fiscal year 2006 may be adopted in accordance
3with this Section by the agency charged with administering that
4provision or initiative, except that the 24-month limitation on
5the adoption of emergency rules and the provisions of Sections
65-115 and 5-125 do not apply to rules adopted under this
7subsection (k). The Department of Healthcare and Family
8Services may also adopt rules under this subsection (k)
9necessary to administer the Illinois Public Aid Code, the
10Senior Citizens and Disabled Persons Property Tax Relief and
11Pharmaceutical Assistance Act, the Senior Citizens and
12Disabled Persons Prescription Drug Discount Program Act (now
13the Illinois Prescription Drug Discount Program Act), and the
14Children's Health Insurance Program Act. The adoption of
15emergency rules authorized by this subsection (k) shall be
16deemed to be necessary for the public interest, safety, and
17welfare.
18    (l) In order to provide for the expeditious and timely
19implementation of the provisions of the State's fiscal year
202007 budget, the Department of Healthcare and Family Services
21may adopt emergency rules during fiscal year 2007, including
22rules effective July 1, 2007, in accordance with this
23subsection to the extent necessary to administer the
24Department's responsibilities with respect to amendments to
25the State plans and Illinois waivers approved by the federal
26Centers for Medicare and Medicaid Services necessitated by the

 

 

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1requirements of Title XIX and Title XXI of the federal Social
2Security Act. The adoption of emergency rules authorized by
3this subsection (l) shall be deemed to be necessary for the
4public interest, safety, and welfare.
5    (m) In order to provide for the expeditious and timely
6implementation of the provisions of the State's fiscal year
72008 budget, the Department of Healthcare and Family Services
8may adopt emergency rules during fiscal year 2008, including
9rules effective July 1, 2008, in accordance with this
10subsection to the extent necessary to administer the
11Department's responsibilities with respect to amendments to
12the State plans and Illinois waivers approved by the federal
13Centers for Medicare and Medicaid Services necessitated by the
14requirements of Title XIX and Title XXI of the federal Social
15Security Act. The adoption of emergency rules authorized by
16this subsection (m) shall be deemed to be necessary for the
17public interest, safety, and welfare.
18    (n) In order to provide for the expeditious and timely
19implementation of the provisions of the State's fiscal year
202010 budget, emergency rules to implement any provision of this
21amendatory Act of the 96th General Assembly or any other budget
22initiative authorized by the 96th General Assembly for fiscal
23year 2010 may be adopted in accordance with this Section by the
24agency charged with administering that provision or
25initiative. The adoption of emergency rules authorized by this
26subsection (n) shall be deemed to be necessary for the public

 

 

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1interest, safety, and welfare. The rulemaking authority
2granted in this subsection (n) shall apply only to rules
3promulgated during Fiscal Year 2010.
4    (o) In order to provide for the expeditious and timely
5implementation of the provisions of the State's fiscal year
62011 budget, emergency rules to implement any provision of this
7amendatory Act of the 96th General Assembly or any other budget
8initiative authorized by the 96th General Assembly for fiscal
9year 2011 may be adopted in accordance with this Section by the
10agency charged with administering that provision or
11initiative. The adoption of emergency rules authorized by this
12subsection (o) is deemed to be necessary for the public
13interest, safety, and welfare. The rulemaking authority
14granted in this subsection (o) applies only to rules
15promulgated on or after the effective date of this amendatory
16Act of the 96th General Assembly through June 30, 2011.
17    (p) In order to provide for the expeditious and timely
18implementation of the provisions of this amendatory Act of the
1997th General Assembly, emergency rules to implement any
20provision of this amendatory Act of the 97th General Assembly
21may be adopted in accordance with this subsection (p) by the
22agency charged with administering that provision or
23initiative. The 150-day limitation of the effective period of
24emergency rules does not apply to rules adopted under this
25subsection (p), and the effective period may continue through
26June 30, 2013. The 24-month limitation on the adoption of

 

 

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1emergency rules does not apply to rules adopted under this
2subsection (p). The adoption of emergency rules authorized by
3this subsection (p) is deemed to be necessary for the public
4interest, safety, and welfare.
5(Source: P.A. 95-12, eff. 7-2-07; 95-331, eff. 8-21-07; 96-45,
6eff. 7-15-09; 96-958, eff. 7-1-10; 96-1500, eff. 1-18-11.)
 
7    Section 12. The Personnel Code is amended by changing
8Section 4d as follows:
 
9    (20 ILCS 415/4d)  (from Ch. 127, par. 63b104d)
10    Sec. 4d. Partial exemptions. The following positions in
11State service are exempt from jurisdictions A, B, and C to the
12extent stated for each, unless those jurisdictions are extended
13as provided in this Act:
14        (1) In each department, board or commission that now
15    maintains or may hereafter maintain a major administrative
16    division, service or office in both Sangamon County and
17    Cook County, 2 private secretaries for the director or
18    chairman thereof, one located in the Cook County office and
19    the other located in the Sangamon County office, shall be
20    exempt from jurisdiction B; in all other departments,
21    boards and commissions one private secretary for the
22    director or chairman thereof shall be exempt from
23    jurisdiction B. In all departments, boards and commissions
24    one confidential assistant for the director or chairman

 

 

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1    thereof shall be exempt from jurisdiction B. This paragraph
2    is subject to such modifications or waiver of the
3    exemptions as may be necessary to assure the continuity of
4    federal contributions in those agencies supported in whole
5    or in part by federal funds.
6        (2) The resident administrative head of each State
7    charitable, penal and correctional institution, the
8    chaplains thereof, and all member, patient and inmate
9    employees are exempt from jurisdiction B.
10        (3) The Civil Service Commission, upon written
11    recommendation of the Director of Central Management
12    Services, shall exempt from jurisdiction B other positions
13    which, in the judgment of the Commission, involve either
14    principal administrative responsibility for the
15    determination of policy or principal administrative
16    responsibility for the way in which policies are carried
17    out, except positions in agencies which receive federal
18    funds if such exemption is inconsistent with federal
19    requirements, and except positions in agencies supported
20    in whole by federal funds.
21        (4) All beauticians and teachers of beauty culture and
22    teachers of barbering, and all positions heretofore paid
23    under Section 1.22 of "An Act to standardize position
24    titles and salary rates", approved June 30, 1943, as
25    amended, shall be exempt from jurisdiction B.
26        (5) Licensed attorneys in positions as legal or

 

 

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1    technical advisors, positions in the Department of Natural
2    Resources requiring incumbents to be either a registered
3    professional engineer or to hold a bachelor's degree in
4    engineering from a recognized college or university,
5    licensed physicians in positions of medical administrator
6    or physician or physician specialist (including
7    psychiatrists), and registered nurses (except those
8    registered nurses employed by the Department of Public
9    Health), except those in positions in agencies which
10    receive federal funds if such exemption is inconsistent
11    with federal requirements and except those in positions in
12    agencies supported in whole by federal funds, are exempt
13    from jurisdiction B only to the extent that the
14    requirements of Section 8b.1, 8b.3 and 8b.5 of this Code
15    need not be met.
16        (6) All positions established outside the geographical
17    limits of the State of Illinois to which appointments of
18    other than Illinois citizens may be made are exempt from
19    jurisdiction B.
20        (7) Staff attorneys reporting directly to individual
21    Commissioners of the Illinois Workers' Compensation
22    Commission are exempt from jurisdiction B.
23        (8) Twenty-one Twenty senior public service
24    administrator positions within the Department of
25    Healthcare and Family Services, as set forth in this
26    paragraph (8), requiring the specific knowledge of

 

 

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1    healthcare administration, healthcare finance, healthcare
2    data analytics, or information technology described are
3    exempt from jurisdiction B only to the extent that the
4    requirements of Sections 8b.1, 8b.3, and 8b.5 of this Code
5    need not be met. The General Assembly finds that these
6    positions are all senior policy makers and have
7    spokesperson authority for the Director of the Department
8    of Healthcare and Family Services. When filling positions
9    so designated, the Director of Healthcare and Family
10    Services shall cause a position description to be published
11    which allots points to various qualifications desired.
12    After scoring qualified applications, the Director shall
13    add Veteran's Preference points as enumerated in Section
14    8b.7 of this Code. The following are the minimum
15    qualifications for the senior public service administrator
16    positions provided for in this paragraph (8):
17            (A) HEALTHCARE ADMINISTRATION.
18                Medical Director: Licensed Medical Doctor in
19            good standing; experience in healthcare payment
20            systems, pay for performance initiatives, medical
21            necessity criteria or federal or State quality
22            improvement programs; preferred experience serving
23            Medicaid patients or experience in population
24            health programs with a large provider, health
25            insurer, government agency, or research
26            institution.

 

 

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1                Chief, Bureau of Quality Management: Advanced
2            degree in health policy or health professional
3            field preferred; at least 3 years experience in
4            implementing or managing healthcare quality
5            improvement initiatives in a clinical setting.
6                Quality Management Bureau: Manager, Care
7            Coordination/Managed Care Quality: Clinical degree
8            or advanced degree in relevant field required;
9            experience in the field of managed care quality
10            improvement, with knowledge of HEDIS measurements,
11            coding, and related data definitions.
12                Quality Management Bureau: Manager, Primary
13            Care Provider Quality and Practice Development:
14            Clinical degree or advanced degree in relevant
15            field required; experience in practice
16            administration in the primary care setting with a
17            provider or a provider association or an
18            accrediting body; knowledge of practice standards
19            for medical homes and best evidence based
20            standards of care for primary care.
21                Director of Care Coordination Contracts and
22            Compliance: Bachelor's degree required; multi-year
23            experience in negotiating managed care contracts,
24            preferably on behalf of a payer; experience with
25            health care contract compliance.
26                Manager, Long Term Care Policy: Bachelor's

 

 

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1            degree required; social work, gerontology, or
2            social service degree preferred; knowledge of
3            Olmstead and other relevant court decisions
4            required; experience working with diverse long
5            term care populations and service systems, federal
6            initiatives to create long term care community
7            options, and home and community-based waiver
8            services required. The General Assembly finds that
9            this position is necessary for the timely and
10            effective implementation of this amendatory Act of
11            the 97th General Assembly.
12                Manager, Behavioral Health Programs: Clinical
13            license or Advanced degree required, preferably in
14            psychology, social work, or relevant field;
15            knowledge of medical necessity criteria and
16            governmental policies and regulations governing
17            the provision of mental health services to
18            Medicaid populations, including children and
19            adults, in community and institutional settings of
20            care. The General Assembly finds that this
21            position is necessary for the timely and effective
22            implementation of this amendatory Act of the 97th
23            General Assembly.
24                Chief, Bureau of Pharmacy Services: Bachelor's
25            degree required; pharmacy degree preferred; in
26            formulary development and management from both a

 

 

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1            clinical and financial perspective, experience in
2            prescription drug utilization review and
3            utilization control policies, knowledge of retail
4            pharmacy reimbursement policies and methodologies
5            and available benchmarks, knowledge of Medicare
6            Part D benefit design.
7                Chief, Bureau of Maternal and Child Health
8            Promotion: Bachelor's degree required, advanced
9            degree preferred, in public health, health care
10            management, or a clinical field; multi-year
11            experience in health care or public health
12            management; knowledge of federal EPSDT
13            requirements and strategies for improving health
14            care for children as well as improving birth
15            outcomes.
16                Director of Dental Program: Bachelor's degree
17            required, advanced degree preferred, in healthcare
18            management or relevant field; experience in
19            healthcare administration; experience in
20            administering dental healthcare programs,
21            knowledge of practice standards for dental care
22            and treatment services; knowledge of the public
23            dental health infrastructure.
24                Manager of Medicare/Medicaid Coordination:
25            Bachelor's degree required, knowledge and
26            experience with Medicare Advantage rules and

 

 

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1            regulations, knowledge of Medicaid laws and
2            policies; experience with contract drafting
3            preferred.
4                Chief, Bureau of Eligibility Integrity:
5            Bachelor's degree required, advanced degree in
6            public administration or business administration
7            preferred; experience equivalent to 4 years of
8            administration in a public or business
9            organization required; experience with managing
10            contract compliance required; knowledge of
11            Medicaid eligibility laws and policy preferred;
12            supervisory experience preferred. The General
13            Assembly finds that this position is necessary for
14            the timely and effective implementation of this
15            amendatory Act of the 97th General Assembly.
16            (B) HEALTHCARE FINANCE.
17                Director of Care Coordination Rate and
18            Finance: MBA, CPA, or Actuarial degree required;
19            experience in managed care rate setting,
20            including, but not limited to, baseline costs and
21            growth trends; knowledge and experience with
22            Medical Loss Ratio standards and measurements.
23                Director of Encounter Data Program: Bachelor's
24            degree required, advanced degree preferred,
25            preferably in business or information systems; at
26            least 2 years healthcare data reporting

 

 

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1            experience, including, but not limited to, data
2            definitions, submission, and editing; strong
3            background in HIPAA transactions relevant to
4            encounter data submission; knowledge of healthcare
5            claims systems.
6                Chief, Bureau of Rate Development and
7            Analysis: Bachelor's degree required, advanced
8            degree preferred, with preferred coursework in
9            business or public administration, accounting,
10            finance, data analysis, or statistics; experience
11            with Medicaid reimbursement methodologies and
12            regulations; experience with extracting data from
13            large systems for analysis.
14                Manager of Medical Finance, Division of
15            Finance: Requires relevant advanced degree or
16            certification in relevant field, such as Certified
17            Public Accountant; coursework in business or
18            public administration, accounting, finance, data
19            analysis, or statistics preferred; experience in
20            control systems and GAAP; financial management
21            experience in a healthcare or government entity
22            utilizing Medicaid funding.
23            (C) HEALTHCARE DATA ANALYTICS.
24                Data Quality Assurance Manager: Bachelor's
25            degree required, advanced degree preferred,
26            preferably in business, information systems, or

 

 

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1            epidemiology; at least 3 years of extensive
2            healthcare data reporting experience with a large
3            provider, health insurer, government agency, or
4            research institution; previous data quality
5            assurance role or formal data quality assurance
6            training.
7                Data Analytics Unit Manager: Bachelor's degree
8            required, advanced degree preferred, in
9            information systems, applied mathematics, or
10            another field with a strong analytics component;
11            extensive healthcare data reporting experience
12            with a large provider, health insurer, government
13            agency, or research institution; experience as a
14            business analyst interfacing between business and
15            information technology departments; in-depth
16            knowledge of health insurance coding and evolving
17            healthcare quality metrics; working knowledge of
18            SQL and/or SAS.
19                Data Analytics Platform Manager: Bachelor's
20            degree required, advanced degree preferred,
21            preferably in business or information systems;
22            extensive healthcare data reporting experience
23            with a large provider, health insurer, government
24            agency, or research institution; previous
25            experience working on a health insurance data
26            analytics platform; experience managing contracts

 

 

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1            and vendors preferred.
2            (D) HEALTHCARE INFORMATION TECHNOLOGY.
3                Manager of Recipient Provider Reference Unit:
4            Bachelor's degree required; experience equivalent
5            to 4 years of administration in a public or
6            business organization; 3 years of administrative
7            experience in a computer-based management
8            information system.
9                Manager of MMIS Claims Unit: Bachelor's degree
10            required, with preferred coursework in business,
11            public administration, information systems;
12            experience equivalent to 4 years of administration
13            in a public or business organization; working
14            knowledge with design and implementation of
15            technical solutions to medical claims payment
16            systems; extensive technical writing experience,
17            including, but not limited to, the development of
18            RFPs, APDs, feasibility studies, and related
19            documents; thorough knowledge of IT system design,
20            commercial off the shelf software packages and
21            hardware components.
22                Assistant Bureau Chief, Office of Information
23            Systems: Bachelor's degree required, with
24            preferred coursework in business, public
25            administration, information systems; experience
26            equivalent to 5 years of administration in a public

 

 

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1            or private business organization; extensive
2            technical writing experience, including, but not
3            limited to, the development of RFPs, APDs,
4            feasibility studies and related documents;
5            extensive healthcare technology experience with a
6            large provider, health insurer, government agency,
7            or research institution; experience as a business
8            analyst interfacing between business and
9            information technology departments; thorough
10            knowledge of IT system design, commercial off the
11            shelf software packages and hardware components.
12                Technical System Architect: Bachelor's degree
13            required, with preferred coursework in computer
14            science or information technology; prior
15            experience equivalent to 5 years of computer
16            science or IT administration in a public or
17            business organization; extensive healthcare
18            technology experience with a large provider,
19            health insurer, government agency, or research
20            institution; experience as a business analyst
21            interfacing between business and information
22            technology departments.
23    The provisions of this paragraph (8), other than this
24    sentence, are inoperative after January 1, 2014.
25(Source: P.A. 97-649, eff. 12-30-11.)
 

 

 

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1    Section 14. The Illinois State Auditing Act is amended by
2adding Section 2-20 as follows:
 
3    (30 ILCS 5/2-20 new)
4    Sec. 2-20. Certification of federal waivers and amendments
5to the Illinois Title XIX State plan.
6    (a) No later than August 1, 2012, the Department shall file
7a report with the Auditor General, the Governor, the Speaker of
8the House of Representatives, the Minority Leader of the House
9of Representatives, the Senate President, and the Senate
10Minority Leader listing any necessary amendment to the Illinois
11Title XIX State plan, federal waiver request, or State
12administrative rule required to implement this amendatory Act
13of the 97th General Assembly.
14    (b) No later than March 1, 2013, the Department shall
15provide evidence to the Auditor General that it has undertaken
16the required actions listed in the report required by
17subsection (a).
18    (c) No later than May 1, 2013, the Auditor General shall
19submit a report to the Governor, the Speaker of the House of
20Representatives, the Minority Leader of the House of
21Representatives, the Senate President, and the Senate Minority
22Leader as to whether the Department has undertaken the required
23actions listed in the report required by subsection (a).
 
24    Section 15. The State Finance Act is amended by changing

 

 

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1Sections 6z-52 and 13.2 as follows:
 
2    (30 ILCS 105/6z-52)
3    Sec. 6z-52. Drug Rebate Fund.
4    (a) There is created in the State Treasury a special fund
5to be known as the Drug Rebate Fund.
6    (b) The Fund is created for the purpose of receiving and
7disbursing moneys in accordance with this Section.
8Disbursements from the Fund shall be made, subject to
9appropriation, only as follows:
10        (1) For payments for reimbursement or coverage for
11    prescription drugs and other pharmacy products provided to
12    a recipient of medical assistance under the Illinois Public
13    Aid Code, the Children's Health Insurance Program Act, the
14    Covering ALL KIDS Health Insurance Act, and the Veterans'
15    Health Insurance Program Act of 2008, and the Senior
16    Citizens and Disabled Persons Property Tax Relief and
17    Pharmaceutical Assistance Act.
18        (2) For reimbursement of moneys collected by the
19    Department of Healthcare and Family Services (formerly
20    Illinois Department of Public Aid) through error or
21    mistake.
22        (3) For payments of any amounts that are reimbursable
23    to the federal government resulting from a payment into
24    this Fund.
25        (4) For payments of operational and administrative

 

 

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1    expenses related to providing and managing coverage for
2    prescription drugs and other pharmacy products provided to
3    a recipient of medical assistance under the Illinois Public
4    Aid Code, the Children's Health Insurance Program Act, the
5    Covering ALL KIDS Health Insurance Act, the Veterans'
6    Health Insurance Program Act of 2008, and the Senior
7    Citizens and Disabled Persons Property Tax Relief and
8    Pharmaceutical Assistance Act.
9    (c) The Fund shall consist of the following:
10        (1) Upon notification from the Director of Healthcare
11    and Family Services, the Comptroller shall direct and the
12    Treasurer shall transfer the net State share (disregarding
13    the reduction in net State share attributable to the
14    American Recovery and Reinvestment Act of 2009 or any other
15    federal economic stimulus program) of all moneys received
16    by the Department of Healthcare and Family Services
17    (formerly Illinois Department of Public Aid) from drug
18    rebate agreements with pharmaceutical manufacturers
19    pursuant to Title XIX of the federal Social Security Act,
20    including any portion of the balance in the Public Aid
21    Recoveries Trust Fund on July 1, 2001 that is attributable
22    to such receipts.
23        (2) All federal matching funds received by the Illinois
24    Department as a result of expenditures made by the
25    Department that are attributable to moneys deposited in the
26    Fund.

 

 

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1        (3) Any premium collected by the Illinois Department
2    from participants under a waiver approved by the federal
3    government relating to provision of pharmaceutical
4    services.
5        (4) All other moneys received for the Fund from any
6    other source, including interest earned thereon.
7(Source: P.A. 95-331, eff. 8-21-07; 96-8, eff. 4-28-09;
896-1100, eff. 1-1-11.)
 
9    (30 ILCS 105/13.2)  (from Ch. 127, par. 149.2)
10    Sec. 13.2. Transfers among line item appropriations.
11    (a) Transfers among line item appropriations from the same
12treasury fund for the objects specified in this Section may be
13made in the manner provided in this Section when the balance
14remaining in one or more such line item appropriations is
15insufficient for the purpose for which the appropriation was
16made.
17    (a-1) No transfers may be made from one agency to another
18agency, nor may transfers be made from one institution of
19higher education to another institution of higher education
20except as provided by subsection (a-4).
21    (a-2) Except as otherwise provided in this Section,
22transfers may be made only among the objects of expenditure
23enumerated in this Section, except that no funds may be
24transferred from any appropriation for personal services, from
25any appropriation for State contributions to the State

 

 

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1Employees' Retirement System, from any separate appropriation
2for employee retirement contributions paid by the employer, nor
3from any appropriation for State contribution for employee
4group insurance. During State fiscal year 2005, an agency may
5transfer amounts among its appropriations within the same
6treasury fund for personal services, employee retirement
7contributions paid by employer, and State Contributions to
8retirement systems; notwithstanding and in addition to the
9transfers authorized in subsection (c) of this Section, the
10fiscal year 2005 transfers authorized in this sentence may be
11made in an amount not to exceed 2% of the aggregate amount
12appropriated to an agency within the same treasury fund. During
13State fiscal year 2007, the Departments of Children and Family
14Services, Corrections, Human Services, and Juvenile Justice
15may transfer amounts among their respective appropriations
16within the same treasury fund for personal services, employee
17retirement contributions paid by employer, and State
18contributions to retirement systems. During State fiscal year
192010, the Department of Transportation may transfer amounts
20among their respective appropriations within the same treasury
21fund for personal services, employee retirement contributions
22paid by employer, and State contributions to retirement
23systems. During State fiscal year 2010 only, an agency may
24transfer amounts among its respective appropriations within
25the same treasury fund for personal services, employee
26retirement contributions paid by employer, and State

 

 

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1contributions to retirement systems. Notwithstanding, and in
2addition to, the transfers authorized in subsection (c) of this
3Section, these transfers may be made in an amount not to exceed
42% of the aggregate amount appropriated to an agency within the
5same treasury fund.
6    (a-3) Further, if an agency receives a separate
7appropriation for employee retirement contributions paid by
8the employer, any transfer by that agency into an appropriation
9for personal services must be accompanied by a corresponding
10transfer into the appropriation for employee retirement
11contributions paid by the employer, in an amount sufficient to
12meet the employer share of the employee contributions required
13to be remitted to the retirement system.
14    (a-4) Long-Term Care Rebalancing. The Governor may
15designate amounts set aside for institutional services
16appropriated from the General Revenue Fund or any other State
17fund that receives monies for long-term care services to be
18transferred to all State agencies responsible for the
19administration of community-based long-term care programs,
20including, but not limited to, community-based long-term care
21programs administered by the Department of Healthcare and
22Family Services, the Department of Human Services, and the
23Department on Aging, provided that the Director of Healthcare
24and Family Services first certifies that the amounts being
25transferred are necessary for the purpose of assisting persons
26in or at risk of being in institutional care to transition to

 

 

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1community-based settings, including the financial data needed
2to prove the need for the transfer of funds. The total amounts
3transferred shall not exceed 4% in total of the amounts
4appropriated from the General Revenue Fund or any other State
5fund that receives monies for long-term care services for each
6fiscal year. A notice of the fund transfer must be made to the
7General Assembly and posted at a minimum on the Department of
8Healthcare and Family Services website, the Governor's Office
9of Management and Budget website, and any other website the
10Governor sees fit. These postings shall serve as notice to the
11General Assembly of the amounts to be transferred. Notice shall
12be given at least 30 days prior to transfer.
13    (b) In addition to the general transfer authority provided
14under subsection (c), the following agencies have the specific
15transfer authority granted in this subsection:
16    The Department of Healthcare and Family Services is
17authorized to make transfers representing savings attributable
18to not increasing grants due to the births of additional
19children from line items for payments of cash grants to line
20items for payments for employment and social services for the
21purposes outlined in subsection (f) of Section 4-2 of the
22Illinois Public Aid Code.
23    The Department of Children and Family Services is
24authorized to make transfers not exceeding 2% of the aggregate
25amount appropriated to it within the same treasury fund for the
26following line items among these same line items: Foster Home

 

 

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1and Specialized Foster Care and Prevention, Institutions and
2Group Homes and Prevention, and Purchase of Adoption and
3Guardianship Services.
4    The Department on Aging is authorized to make transfers not
5exceeding 2% of the aggregate amount appropriated to it within
6the same treasury fund for the following Community Care Program
7line items among these same line items: Homemaker and Senior
8Companion Services, Alternative Senior Services, Case
9Coordination Units, and Adult Day Care Services.
10    The State Treasurer is authorized to make transfers among
11line item appropriations from the Capital Litigation Trust
12Fund, with respect to costs incurred in fiscal years 2002 and
132003 only, when the balance remaining in one or more such line
14item appropriations is insufficient for the purpose for which
15the appropriation was made, provided that no such transfer may
16be made unless the amount transferred is no longer required for
17the purpose for which that appropriation was made.
18    The State Board of Education is authorized to make
19transfers from line item appropriations within the same
20treasury fund for General State Aid and General State Aid -
21Hold Harmless, provided that no such transfer may be made
22unless the amount transferred is no longer required for the
23purpose for which that appropriation was made, to the line item
24appropriation for Transitional Assistance when the balance
25remaining in such line item appropriation is insufficient for
26the purpose for which the appropriation was made.

 

 

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1    The State Board of Education is authorized to make
2transfers between the following line item appropriations
3within the same treasury fund: Disabled Student
4Services/Materials (Section 14-13.01 of the School Code),
5Disabled Student Transportation Reimbursement (Section
614-13.01 of the School Code), Disabled Student Tuition -
7Private Tuition (Section 14-7.02 of the School Code),
8Extraordinary Special Education (Section 14-7.02b of the
9School Code), Reimbursement for Free Lunch/Breakfast Program,
10Summer School Payments (Section 18-4.3 of the School Code), and
11Transportation - Regular/Vocational Reimbursement (Section
1229-5 of the School Code). Such transfers shall be made only
13when the balance remaining in one or more such line item
14appropriations is insufficient for the purpose for which the
15appropriation was made and provided that no such transfer may
16be made unless the amount transferred is no longer required for
17the purpose for which that appropriation was made.
18    The During State fiscal years 2010 and 2011 only, the
19Department of Healthcare and Family Services is authorized to
20make transfers not exceeding 4% of the aggregate amount
21appropriated to it, within the same treasury fund, among the
22various line items appropriated for Medical Assistance.
23    (c) The sum of such transfers for an agency in a fiscal
24year shall not exceed 2% of the aggregate amount appropriated
25to it within the same treasury fund for the following objects:
26Personal Services; Extra Help; Student and Inmate

 

 

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1Compensation; State Contributions to Retirement Systems; State
2Contributions to Social Security; State Contribution for
3Employee Group Insurance; Contractual Services; Travel;
4Commodities; Printing; Equipment; Electronic Data Processing;
5Operation of Automotive Equipment; Telecommunications
6Services; Travel and Allowance for Committed, Paroled and
7Discharged Prisoners; Library Books; Federal Matching Grants
8for Student Loans; Refunds; Workers' Compensation,
9Occupational Disease, and Tort Claims; and, in appropriations
10to institutions of higher education, Awards and Grants.
11Notwithstanding the above, any amounts appropriated for
12payment of workers' compensation claims to an agency to which
13the authority to evaluate, administer and pay such claims has
14been delegated by the Department of Central Management Services
15may be transferred to any other expenditure object where such
16amounts exceed the amount necessary for the payment of such
17claims.
18    (c-1) Special provisions for State fiscal year 2003.
19Notwithstanding any other provision of this Section to the
20contrary, for State fiscal year 2003 only, transfers among line
21item appropriations to an agency from the same treasury fund
22may be made provided that the sum of such transfers for an
23agency in State fiscal year 2003 shall not exceed 3% of the
24aggregate amount appropriated to that State agency for State
25fiscal year 2003 for the following objects: personal services,
26except that no transfer may be approved which reduces the

 

 

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1aggregate appropriations for personal services within an
2agency; extra help; student and inmate compensation; State
3contributions to retirement systems; State contributions to
4social security; State contributions for employee group
5insurance; contractual services; travel; commodities;
6printing; equipment; electronic data processing; operation of
7automotive equipment; telecommunications services; travel and
8allowance for committed, paroled, and discharged prisoners;
9library books; federal matching grants for student loans;
10refunds; workers' compensation, occupational disease, and tort
11claims; and, in appropriations to institutions of higher
12education, awards and grants.
13    (c-2) Special provisions for State fiscal year 2005.
14Notwithstanding subsections (a), (a-2), and (c), for State
15fiscal year 2005 only, transfers may be made among any line
16item appropriations from the same or any other treasury fund
17for any objects or purposes, without limitation, when the
18balance remaining in one or more such line item appropriations
19is insufficient for the purpose for which the appropriation was
20made, provided that the sum of those transfers by a State
21agency shall not exceed 4% of the aggregate amount appropriated
22to that State agency for fiscal year 2005.
23    (d) Transfers among appropriations made to agencies of the
24Legislative and Judicial departments and to the
25constitutionally elected officers in the Executive branch
26require the approval of the officer authorized in Section 10 of

 

 

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1this Act to approve and certify vouchers. Transfers among
2appropriations made to the University of Illinois, Southern
3Illinois University, Chicago State University, Eastern
4Illinois University, Governors State University, Illinois
5State University, Northeastern Illinois University, Northern
6Illinois University, Western Illinois University, the Illinois
7Mathematics and Science Academy and the Board of Higher
8Education require the approval of the Board of Higher Education
9and the Governor. Transfers among appropriations to all other
10agencies require the approval of the Governor.
11    The officer responsible for approval shall certify that the
12transfer is necessary to carry out the programs and purposes
13for which the appropriations were made by the General Assembly
14and shall transmit to the State Comptroller a certified copy of
15the approval which shall set forth the specific amounts
16transferred so that the Comptroller may change his records
17accordingly. The Comptroller shall furnish the Governor with
18information copies of all transfers approved for agencies of
19the Legislative and Judicial departments and transfers
20approved by the constitutionally elected officials of the
21Executive branch other than the Governor, showing the amounts
22transferred and indicating the dates such changes were entered
23on the Comptroller's records.
24    (e) The State Board of Education, in consultation with the
25State Comptroller, may transfer line item appropriations for
26General State Aid between the Common School Fund and the

 

 

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1Education Assistance Fund. With the advice and consent of the
2Governor's Office of Management and Budget, the State Board of
3Education, in consultation with the State Comptroller, may
4transfer line item appropriations between the General Revenue
5Fund and the Education Assistance Fund for the following
6programs:
7        (1) Disabled Student Personnel Reimbursement (Section
8    14-13.01 of the School Code);
9        (2) Disabled Student Transportation Reimbursement
10    (subsection (b) of Section 14-13.01 of the School Code);
11        (3) Disabled Student Tuition - Private Tuition
12    (Section 14-7.02 of the School Code);
13        (4) Extraordinary Special Education (Section 14-7.02b
14    of the School Code);
15        (5) Reimbursement for Free Lunch/Breakfast Programs;
16        (6) Summer School Payments (Section 18-4.3 of the
17    School Code);
18        (7) Transportation - Regular/Vocational Reimbursement
19    (Section 29-5 of the School Code);
20        (8) Regular Education Reimbursement (Section 18-3 of
21    the School Code); and
22        (9) Special Education Reimbursement (Section 14-7.03
23    of the School Code).
24(Source: P.A. 95-707, eff. 1-11-08; 96-37, eff. 7-13-09;
2596-820, eff. 11-18-09; 96-959, eff. 7-1-10; 96-1086, eff.
267-16-10; 96-1501, eff. 1-25-11.)
 

 

 

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1    (30 ILCS 105/5.441 rep.)
2    (30 ILCS 105/5.442 rep.)
3    (30 ILCS 105/5.549 rep.)
4    Section 20. The State Finance Act is amended by repealing
5Sections 5.441, 5.442, and 5.549.
 
6    Section 25. The Illinois Procurement Code is amended by
7changing Section 1-10 as follows:
 
8    (30 ILCS 500/1-10)
9    Sec. 1-10. Application.
10    (a) This Code applies only to procurements for which
11contractors were first solicited on or after July 1, 1998. This
12Code shall not be construed to affect or impair any contract,
13or any provision of a contract, entered into based on a
14solicitation prior to the implementation date of this Code as
15described in Article 99, including but not limited to any
16covenant entered into with respect to any revenue bonds or
17similar instruments. All procurements for which contracts are
18solicited between the effective date of Articles 50 and 99 and
19July 1, 1998 shall be substantially in accordance with this
20Code and its intent.
21    (b) This Code shall apply regardless of the source of the
22funds with which the contracts are paid, including federal
23assistance moneys. This Code shall not apply to:

 

 

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1        (1) Contracts between the State and its political
2    subdivisions or other governments, or between State
3    governmental bodies except as specifically provided in
4    this Code.
5        (2) Grants, except for the filing requirements of
6    Section 20-80.
7        (3) Purchase of care.
8        (4) Hiring of an individual as employee and not as an
9    independent contractor, whether pursuant to an employment
10    code or policy or by contract directly with that
11    individual.
12        (5) Collective bargaining contracts.
13        (6) Purchase of real estate, except that notice of this
14    type of contract with a value of more than $25,000 must be
15    published in the Procurement Bulletin within 7 days after
16    the deed is recorded in the county of jurisdiction. The
17    notice shall identify the real estate purchased, the names
18    of all parties to the contract, the value of the contract,
19    and the effective date of the contract.
20        (7) Contracts necessary to prepare for anticipated
21    litigation, enforcement actions, or investigations,
22    provided that the chief legal counsel to the Governor shall
23    give his or her prior approval when the procuring agency is
24    one subject to the jurisdiction of the Governor, and
25    provided that the chief legal counsel of any other
26    procuring entity subject to this Code shall give his or her

 

 

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1    prior approval when the procuring entity is not one subject
2    to the jurisdiction of the Governor.
3        (8) Contracts for services to Northern Illinois
4    University by a person, acting as an independent
5    contractor, who is qualified by education, experience, and
6    technical ability and is selected by negotiation for the
7    purpose of providing non-credit educational service
8    activities or products by means of specialized programs
9    offered by the university.
10        (9) Procurement expenditures by the Illinois
11    Conservation Foundation when only private funds are used.
12        (10) Procurement expenditures by the Illinois Health
13    Information Exchange Authority involving private funds
14    from the Health Information Exchange Fund. "Private funds"
15    means gifts, donations, and private grants.
16        (11) Public-private agreements entered into according
17    to the procurement requirements of Section 20 of the
18    Public-Private Partnerships for Transportation Act and
19    design-build agreements entered into according to the
20    procurement requirements of Section 25 of the
21    Public-Private Partnerships for Transportation Act.
22    (c) This Code does not apply to the electric power
23procurement process provided for under Section 1-75 of the
24Illinois Power Agency Act and Section 16-111.5 of the Public
25Utilities Act.
26    (d) Except for Section 20-160 and Article 50 of this Code,

 

 

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1and as expressly required by Section 9.1 of the Illinois
2Lottery Law, the provisions of this Code do not apply to the
3procurement process provided for under Section 9.1 of the
4Illinois Lottery Law.
5    (e) This Code does not apply to the process used by the
6Capital Development Board to retain a person or entity to
7assist the Capital Development Board with its duties related to
8the determination of costs of a clean coal SNG brownfield
9facility, as defined by Section 1-10 of the Illinois Power
10Agency Act, as required in subsection (h-3) of Section 9-220 of
11the Public Utilities Act, including calculating the range of
12capital costs, the range of operating and maintenance costs, or
13the sequestration costs or monitoring the construction of clean
14coal SNG brownfield facility for the full duration of
15construction.
16    (f) This Code does not apply to the process used by the
17Illinois Power Agency to retain a mediator to mediate sourcing
18agreement disputes between gas utilities and the clean coal SNG
19brownfield facility, as defined in Section 1-10 of the Illinois
20Power Agency Act, as required under subsection (h-1) of Section
219-220 of the Public Utilities Act.
22    (g) (e) This Code does not apply to the processes used by
23the Illinois Power Agency to retain a mediator to mediate
24contract disputes between gas utilities and the clean coal SNG
25facility and to retain an expert to assist in the review of
26contracts under subsection (h) of Section 9-220 of the Public

 

 

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1Utilities Act. This Code does not apply to the process used by
2the Illinois Commerce Commission to retain an expert to assist
3in determining the actual incurred costs of the clean coal SNG
4facility and the reasonableness of those costs as required
5under subsection (h) of Section 9-220 of the Public Utilities
6Act.
7    (h) This Code does not apply to the process to procure or
8contracts entered into in accordance with Sections 11-5.2 and
911-5.3 of the Illinois Public Aid Code.
10(Source: P.A. 96-840, eff. 12-23-09; 96-1331, eff. 7-27-10;
1197-96, eff. 7-13-11; 97-239, eff. 8-2-11; 97-502, eff. 8-23-11;
12revised 9-7-11.)
 
13    (30 ILCS 775/Act rep.)
14    Section 30. The Excellence in Academic Medicine Act is
15repealed.
 
16    Section 45. The Nursing Home Care Act is amended by
17changing Section 3-202.05 as follows:
 
18    (210 ILCS 45/3-202.05)
19    Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
20thereafter.
21    (a) For the purpose of computing staff to resident ratios,
22direct care staff shall include:
23        (1) registered nurses;

 

 

SB2840 Enrolled- 40 -LRB097 15631 KTG 62714 b

1        (2) licensed practical nurses;
2        (3) certified nurse assistants;
3        (4) psychiatric services rehabilitation aides;
4        (5) rehabilitation and therapy aides;
5        (6) psychiatric services rehabilitation coordinators;
6        (7) assistant directors of nursing;
7        (8) 50% of the Director of Nurses' time; and
8        (9) 30% of the Social Services Directors' time.
9    The Department shall, by rule, allow certain facilities
10subject to 77 Ill. Admin. Code 300.4000 and following (Subpart
11S) and 300.6000 and following (Subpart T) to utilize
12specialized clinical staff, as defined in rules, to count
13towards the staffing ratios.
14    Within 120 days of the effective date of this amendatory
15Act of the 97th General Assembly, the Department shall
16promulgate rules specific to the staffing requirements for
17facilities federally defined as Institutions for Mental
18Disease. These rules shall recognize the unique nature of
19individuals with chronic mental health conditions, shall
20include minimum requirements for specialized clinical staff,
21including clinical social workers, psychiatrists,
22psychologists, and direct care staff set forth in paragraphs
23(4) through (6) and any other specialized staff which may be
24utilized and deemed necessary to count toward staffing ratios.
25    Within 120 days of the effective date of this amendatory
26Act of the 97th General Assembly, the Department shall

 

 

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1promulgate rules specific to the staffing requirements for
2facilities licensed under the Specialized Mental Health
3Rehabilitation Act. These rules shall recognize the unique
4nature of individuals with chronic mental health conditions,
5shall include minimum requirements for specialized clinical
6staff, including clinical social workers, psychiatrists,
7psychologists, and direct care staff set forth in paragraphs
8(4) through (6) and any other specialized staff which may be
9utilized and deemed necessary to count toward staffing ratios.
10    (b) Beginning January 1, 2011, and thereafter, light
11intermediate care shall be staffed at the same staffing ratio
12as intermediate care.
13    (c) Facilities shall notify the Department within 60 days
14after the effective date of this amendatory Act of the 96th
15General Assembly, in a form and manner prescribed by the
16Department, of the staffing ratios in effect on the effective
17date of this amendatory Act of the 96th General Assembly for
18both intermediate and skilled care and the number of residents
19receiving each level of care.
20    (d)(1) Effective July 1, 2010, for each resident needing
21skilled care, a minimum staffing ratio of 2.5 hours of nursing
22and personal care each day must be provided; for each resident
23needing intermediate care, 1.7 hours of nursing and personal
24care each day must be provided.
25    (2) Effective January 1, 2011, the minimum staffing ratios
26shall be increased to 2.7 hours of nursing and personal care

 

 

SB2840 Enrolled- 42 -LRB097 15631 KTG 62714 b

1each day for a resident needing skilled care and 1.9 hours of
2nursing and personal care each day for a resident needing
3intermediate care.
4    (3) Effective January 1, 2012, the minimum staffing ratios
5shall be increased to 3.0 hours of nursing and personal care
6each day for a resident needing skilled care and 2.1 hours of
7nursing and personal care each day for a resident needing
8intermediate care.
9    (4) Effective January 1, 2013, the minimum staffing ratios
10shall be increased to 3.4 hours of nursing and personal care
11each day for a resident needing skilled care and 2.3 hours of
12nursing and personal care each day for a resident needing
13intermediate care.
14    (5) Effective January 1, 2014, the minimum staffing ratios
15shall be increased to 3.8 hours of nursing and personal care
16each day for a resident needing skilled care and 2.5 hours of
17nursing and personal care each day for a resident needing
18intermediate care.
19    (e) Ninety days after the effective date of this amendatory
20Act of the 97th General Assembly, a minimum of 25% of nursing
21and personal care time shall be provided by licensed nurses,
22with at least 10% of nursing and personal care time provided by
23registered nurses. These minimum requirements shall remain in
24effect until an acuity based registered nurse requirement is
25promulgated by rule concurrent with the adoption of the
26Resource Utilization Group classification-based payment

 

 

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1methodology, as provided in Section 5-5.2 of the Illinois
2Public Aid Code. Registered nurses and licensed practical
3nurses employed by a facility in excess of these requirements
4may be used to satisfy the remaining 75% of the nursing and
5personal care time requirements. Notwithstanding this
6subsection, no staffing requirement in statute in effect on the
7effective date of this amendatory Act of the 97th General
8Assembly shall be reduced on account of this subsection.
9(Source: P.A. 96-1372, eff. 7-29-10; 96-1504, eff. 1-27-11.)
 
10    Section 50. The Emergency Medical Services (EMS) Systems
11Act is amended by changing Section 3.86 as follows:
 
12    (210 ILCS 50/3.86)
13    Sec. 3.86. Stretcher van providers.
14    (a) In this Section, "stretcher van provider" means an
15entity licensed by the Department to provide non-emergency
16transportation of passengers on a stretcher in compliance with
17this Act or the rules adopted by the Department pursuant to
18this Act, utilizing stretcher vans.
19    (b) The Department has the authority and responsibility to
20do the following:
21        (1) Require all stretcher van providers, both publicly
22    and privately owned, to be licensed by the Department.
23        (2) Establish licensing and safety standards and
24    requirements for stretcher van providers, through rules

 

 

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1    adopted pursuant to this Act, including but not limited to:
2            (A) Vehicle design, specification, operation, and
3        maintenance standards.
4            (B) Safety equipment requirements and standards.
5            (C) Staffing requirements.
6            (D) Annual license renewal.
7        (3) License all stretcher van providers that have met
8    the Department's requirements for licensure.
9        (4) Annually inspect all licensed stretcher van
10    providers, and relicense providers that have met the
11    Department's requirements for license renewal.
12        (5) Suspend, revoke, refuse to issue, or refuse to
13    renew the license of any stretcher van provider, or that
14    portion of a license pertaining to a specific vehicle
15    operated by a provider, after an opportunity for a hearing,
16    when findings show that the provider or one or more of its
17    vehicles has failed to comply with the standards and
18    requirements of this Act or the rules adopted by the
19    Department pursuant to this Act.
20        (6) Issue an emergency suspension order for any
21    provider or vehicle licensed under this Act when the
22    Director or his or her designee has determined that an
23    immediate or serious danger to the public health, safety,
24    and welfare exists. Suspension or revocation proceedings
25    that offer an opportunity for a hearing shall be promptly
26    initiated after the emergency suspension order has been

 

 

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1    issued.
2        (7) Prohibit any stretcher van provider from
3    advertising, identifying its vehicles, or disseminating
4    information in a false or misleading manner concerning the
5    provider's type and level of vehicles, location, response
6    times, level of personnel, licensure status, or EMS System
7    participation.
8        (8) Charge each stretcher van provider a fee, to be
9    submitted with each application for licensure and license
10    renewal.
11    (c) A stretcher van provider may provide transport of a
12passenger on a stretcher, provided the passenger meets all of
13the following requirements:
14        (1) (Blank). He or she needs no medical equipment,
15    except self-administered medications.
16        (2) He or she needs no medical monitoring or clinical
17    observation medical observation.
18        (3) He or she needs routine transportation to or from a
19    medical appointment or service if the passenger is
20    convalescent or otherwise bed-confined and does not
21    require clinical observation medical monitoring, aid,
22    care, or treatment during transport.
23    (d) A stretcher van provider may not transport a passenger
24who meets any of the following conditions:
25        (1) He or she is being transported to a hospital for
26    emergency medical treatment. He or she is currently

 

 

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1    admitted to a hospital or is being transported to a
2    hospital for admission or emergency treatment.
3        (2) He or she is experiencing an emergency medical
4    condition or needs active medical monitoring, including
5    isolation precautions, supplemental oxygen that is not
6    self-administered, continuous airway management,
7    suctioning during transport, or the administration of
8    intravenous fluids during transport. He or she is acutely
9    ill, wounded, or medically unstable as determined by a
10    licensed physician.
11        (3) He or she is experiencing an emergency medical
12    condition, an acute medical condition, an exacerbation of a
13    chronic medical condition, or a sudden illness or injury.
14        (4) He or she was administered a medication that might
15    prevent the passenger from caring for himself or herself.
16        (5) He or she was moved from one environment where
17    24-hour medical monitoring or medical observation will
18    take place by certified or licensed nursing personnel to
19    another such environment. Such environments shall include,
20    but not be limited to, hospitals licensed under the
21    Hospital Licensing Act or operated under the University of
22    Illinois Hospital Act, and nursing facilities licensed
23    under the Nursing Home Care Act.
24    (e) The Stretcher Van Licensure Fund is created as a
25special fund within the State treasury. All fees received by
26the Department in connection with the licensure of stretcher

 

 

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1van providers under this Section shall be deposited into the
2fund. Moneys in the fund shall be subject to appropriation to
3the Department for use in implementing this Section.
4(Source: P.A. 96-702, eff. 8-25-09; 96-1469, eff. 1-1-11.)
 
5    Section 53. The Long Term Acute Care Hospital Quality
6Improvement Transfer Program Act is amended by changing
7Sections 35, 40, and 45 and by adding Section 55 as follows:
 
8    (210 ILCS 155/35)
9    Sec. 35. LTAC supplemental per diem rate.
10    (a) The Department must pay an LTAC supplemental per diem
11rate calculated under this Section to LTAC hospitals that meet
12the requirements of Section 15 of this Act for patients:
13        (1) who upon admission to the LTAC hospital meet LTAC
14    hospital criteria; and
15        (2) whose care is primarily paid for by the Department
16    under Title XIX of the Social Security Act or whose care is
17    primarily paid for by the Department after the patient has
18    exhausted his or her benefits under Medicare.
19    (b) The Department must not pay the LTAC supplemental per
20diem rate calculated under this Section if any of the following
21conditions are met:
22        (1) the LTAC hospital no longer meets the requirements
23    under Section 15 of this Act or terminates the agreement
24    specified under Section 15 of this Act;

 

 

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1        (2) the patient does not meet the LTAC hospital
2    criteria upon admission; or
3        (3) the patient's care is primarily paid for by
4    Medicare and the patient has not exhausted his or her
5    Medicare benefits, resulting in the Department becoming
6    the primary payer.
7    (c) The Department may adjust the LTAC supplemental per
8diem rate calculated under this Section based only on the
9conditions and requirements described under Section 40 and
10Section 45 of this Act.
11    (d) The LTAC supplemental per diem rate shall be calculated
12using the LTAC hospital's inflated cost per diem, defined in
13subsection (f) of this Section, and subtracting the following:
14        (1) The LTAC hospital's Medicaid per diem inpatient
15    rate as calculated under 89 Ill. Adm. Code 148.270(c)(4).
16        (2) The LTAC hospital's disproportionate share (DSH)
17    rate as calculated under 89 Ill. Adm. Code 148.120.
18        (3) The LTAC hospital's Medicaid Percentage Adjustment
19    (MPA) rate as calculated under 89 Ill. Adm. Code 148.122.
20        (4) The LTAC hospital's Medicaid High Volume
21    Adjustment (MHVA) rate as calculated under 89 Ill. Adm.
22    Code 148.290(d).
23    (e) LTAC supplemental per diem rates are effective July 1,
242012 shall be the amount in effect as of October 1, 2010. No
25new hospital may qualify for the program after the effective
26date of this amendatory Act of the 97th General Assembly for 12

 

 

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1months beginning on October 1 of each year and must be updated
2every 12 months.
3    (f) For the purposes of this Section, "inflated cost per
4diem" means the quotient resulting from dividing the hospital's
5inpatient Medicaid costs by the hospital's Medicaid inpatient
6days and inflating it to the most current period using
7methodologies consistent with the calculation of the rates
8described in paragraphs (2), (3), and (4) of subsection (d).
9The data is obtained from the LTAC hospital's most recent cost
10report submitted to the Department as mandated under 89 Ill.
11Adm. Code 148.210.
12    (g) On and after July 1, 2012, the Department shall reduce
13any rate of reimbursement for services or other payments or
14alter any methodologies authorized by this Act or the Illinois
15Public Aid Code to reduce any rate of reimbursement for
16services or other payments in accordance with Section 5-5e of
17the Illinois Public Aid Code.
18(Source: P.A. 96-1130, eff. 7-20-10.)
 
19    (210 ILCS 155/40)
20    Sec. 40. Rate adjustments for quality measures.
21    (a) The Department may adjust the LTAC supplemental per
22diem rate calculated under Section 35 of this Act based on the
23requirements of this Section.
24    (b) After the first year of operation of the Program
25established by this Act, the Department may reduce the LTAC

 

 

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1supplemental per diem rate calculated under Section 35 of this
2Act by no more than 5% for an LTAC hospital that does not meet
3benchmarks or targets set by the Department under paragraph (2)
4of subsection (b) of Section 50.
5    (c) After the first year of operation of the Program
6established by this Act, the Department may increase the LTAC
7supplemental per diem rate calculated under Section 35 of this
8Act by no more than 5% for an LTAC hospital that exceeds the
9benchmarks or targets set by the Department under paragraph (2)
10of subsection (a) of Section 50.
11    (d) If an LTAC hospital misses a majority of the benchmarks
12for quality measures for 3 consecutive years, the Department
13may reduce the LTAC supplemental per diem rate calculated under
14Section 35 of this Act to zero.
15    (e) An LTAC hospital whose rate is reduced under subsection
16(d) of this Section may have the LTAC supplemental per diem
17rate calculated under Section 35 of this Act reinstated once
18the LTAC hospital achieves the necessary benchmarks or targets.
19    (f) The Department may apply the reduction described in
20subsection (d) of this Section after one year instead of 3 to
21an LTAC hospital that has had its rate previously reduced under
22subsection (d) of this Section and later has had it reinstated
23under subsection (e) of this Section.
24    (g) The rate adjustments described in this Section shall be
25determined and applied only at the beginning of each rate year.
26    (h) On and after July 1, 2012, the Department shall reduce

 

 

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1any rate of reimbursement for services or other payments or
2alter any methodologies authorized by this Act or the Illinois
3Public Aid Code to reduce any rate of reimbursement for
4services or other payments in accordance with Section 5-5e of
5the Illinois Public Aid Code.
6(Source: P.A. 96-1130, eff. 7-20-10.)
 
7    (210 ILCS 155/45)
8    Sec. 45. Program evaluation.
9    (a) By After the Program completes the 3rd full year of
10operation on September 30, 2012 2013, the Department must
11complete an evaluation of the Program to determine the actual
12savings or costs generated by the Program, both on an aggregate
13basis and on an LTAC hospital-specific basis. The evaluation
14must be conducted in each subsequent year.
15    (b) The Department shall consult with and qualified LTAC
16hospitals to must determine the appropriate methodology to
17accurately calculate the Program's savings and costs. The
18calculation shall take into consideration, but shall not be
19limited to, the length of stay in an acute care hospital prior
20to transfer, the length of stay in the LTAC taking into account
21the acuity of the patient at the time of the LTAC admission,
22and admissions to the LTAC from settings other than an STAC
23hospital.
24    (c) The evaluation must also determine the effects the
25Program has had in improving patient satisfaction and health

 

 

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1outcomes.
2    (d) If the evaluation indicates that the Program generates
3a net cost to the Department, the Department may prospectively
4adjust an individual hospital's LTAC supplemental per diem rate
5under Section 35 of this Act to establish cost neutrality. The
6rate adjustments applied under this subsection (d) do not need
7to be applied uniformly to all qualified LTAC hospitals as long
8as the adjustments are based on data from the evaluation on
9hospital-specific information. Cost neutrality under this
10Section means that the cost to the Department resulting from
11the LTAC supplemental per diem rate must not exceed the savings
12generated from transferring the patient from a STAC hospital.
13    (e) The rate adjustment described in subsection (d) of this
14Section, if necessary, shall be applied to the LTAC
15supplemental per diem rate for the rate year beginning October
161, 2014. The Department may apply this rate adjustment in
17subsequent rate years if the conditions under subsection (d) of
18this Section are met. The Department must apply the rate
19adjustment to an individual LTAC hospital's LTAC supplemental
20per diem rate only in years when the Program evaluation
21indicates a net cost for the Department.
22    (f) The Department may establish a shared savings program
23for qualified LTAC hospitals. The rate adjustments described in
24this Section shall be determined and applied only at the
25beginning of each rate year.
26(Source: P.A. 96-1130, eff. 7-20-10.)
 

 

 

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1    (210 ILCS 155/55 new)
2    Sec. 55. Demonstration care coordination program for
3post-acute care.
4    (a) The Department may develop a demonstration care
5coordination program for LTAC hospital appropriate patients
6with the goal of improving the continuum of care for patients
7who have been discharged from an LTAC hospital.
8    (b) The program shall require risk-sharing and quality
9targets.
 
10    Section 65. The Children's Health Insurance Program Act is
11amended by changing Sections 25 and 40 as follows:
 
12    (215 ILCS 106/25)
13    Sec. 25. Health benefits for children.
14    (a) The Department shall, subject to appropriation,
15provide health benefits coverage to eligible children by:
16        (1) Subsidizing the cost of privately sponsored health
17    insurance, including employer based health insurance, to
18    assist families to take advantage of available privately
19    sponsored health insurance for their eligible children;
20    and
21        (2) Purchasing or providing health care benefits for
22    eligible children. The health benefits provided under this
23    subdivision (a)(2) shall, subject to appropriation and

 

 

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1    without regard to any applicable cost sharing under Section
2    30, be identical to the benefits provided for children
3    under the State's approved plan under Title XIX of the
4    Social Security Act. Providers under this subdivision
5    (a)(2) shall be subject to approval by the Department to
6    provide health care under the Illinois Public Aid Code and
7    shall be reimbursed at the same rate as providers under the
8    State's approved plan under Title XIX of the Social
9    Security Act. In addition, providers may retain
10    co-payments when determined appropriate by the Department.
11    (b) The subsidization provided pursuant to subdivision
12(a)(1) shall be credited to the family of the eligible child.
13    (c) The Department is prohibited from denying coverage to a
14child who is enrolled in a privately sponsored health insurance
15plan pursuant to subdivision (a)(1) because the plan does not
16meet federal benchmarking standards or cost sharing and
17contribution requirements. To be eligible for inclusion in the
18Program, the plan shall contain comprehensive major medical
19coverage which shall consist of physician and hospital
20inpatient services. The Department is prohibited from denying
21coverage to a child who is enrolled in a privately sponsored
22health insurance plan pursuant to subdivision (a)(1) because
23the plan offers benefits in addition to physician and hospital
24inpatient services.
25    (d) The total dollar amount of subsidizing coverage per
26child per month pursuant to subdivision (a)(1) shall be equal

 

 

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1to the average dollar payments, less premiums incurred, per
2child per month pursuant to subdivision (a)(2). The Department
3shall set this amount prospectively based upon the prior fiscal
4year's experience adjusted for incurred but not reported claims
5and estimated increases or decreases in the cost of medical
6care. Payments obligated before July 1, 1999, will be computed
7using State Fiscal Year 1996 payments for children eligible for
8Medical Assistance and income assistance under the Aid to
9Families with Dependent Children Program, with appropriate
10adjustments for cost and utilization changes through January 1,
111999. The Department is prohibited from providing a subsidy
12pursuant to subdivision (a)(1) that is more than the
13individual's monthly portion of the premium.
14    (e) An eligible child may obtain immediate coverage under
15this Program only once during a medical visit. If coverage
16lapses, re-enrollment shall be completed in advance of the next
17covered medical visit and the first month's required premium
18shall be paid in advance of any covered medical visit.
19    (f) In order to accelerate and facilitate the development
20of networks to deliver services to children in areas outside
21counties with populations in excess of 3,000,000, in the event
22less than 25% of the eligible children in a county or
23contiguous counties has enrolled with a Health Maintenance
24Organization pursuant to Section 5-11 of the Illinois Public
25Aid Code, the Department may develop and implement
26demonstration projects to create alternative networks designed

 

 

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1to enhance enrollment and participation in the program. The
2Department shall prescribe by rule the criteria, standards, and
3procedures for effecting demonstration projects under this
4Section.
5    (g) On and after July 1, 2012, the Department shall reduce
6any rate of reimbursement for services or other payments or
7alter any methodologies authorized by this Act or the Illinois
8Public Aid Code to reduce any rate of reimbursement for
9services or other payments in accordance with Section 5-5e of
10the Illinois Public Aid Code.
11(Source: P.A. 90-736, eff. 8-12-98.)
 
12    (215 ILCS 106/40)
13    Sec. 40. Waivers. (a) The Department shall request any
14necessary waivers of federal requirements in order to allow
15receipt of federal funding. for:
16        (1) the coverage of families with eligible children
17    under this Act; and
18        (2) the coverage of children who would otherwise be
19    eligible under this Act, but who have health insurance.
20    (b) The failure of the responsible federal agency to
21approve a waiver for children who would otherwise be eligible
22under this Act but who have health insurance shall not prevent
23the implementation of any Section of this Act provided that
24there are sufficient appropriated funds.
25    (c) Eligibility of a person under an approved waiver due to

 

 

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1the relationship with a child pursuant to Article V of the
2Illinois Public Aid Code or this Act shall be limited to such a
3person whose countable income is determined by the Department
4to be at or below such income eligibility standard as the
5Department by rule shall establish. The income level
6established by the Department shall not be below 90% of the
7federal poverty level. Such persons who are determined to be
8eligible must reapply, or otherwise establish eligibility, at
9least annually. An eligible person shall be required, as
10determined by the Department by rule, to report promptly those
11changes in income and other circumstances that affect
12eligibility. The eligibility of a person may be redetermined
13based on the information reported or may be terminated based on
14the failure to report or failure to report accurately. A person
15may also be held liable to the Department for any payments made
16by the Department on such person's behalf that were
17inappropriate. An applicant shall be provided with notice of
18these obligations.
19(Source: P.A. 96-328, eff. 8-11-09.)
 
20    Section 70. The Covering ALL KIDS Health Insurance Act is
21amended by changing Sections 30 and 35 as follows:
 
22    (215 ILCS 170/30)
23    (Section scheduled to be repealed on July 1, 2016)
24    Sec. 30. Program outreach and marketing. The Department may

 

 

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1provide grants to application agents and other community-based
2organizations to educate the public about the availability of
3the Program. The Department shall adopt rules regarding
4performance standards and outcomes measures expected of
5organizations that are awarded grants under this Section,
6including penalties for nonperformance of contract standards.
7    The Department shall annually publish electronically on a
8State website and in no less than 2 newspapers in the State the
9premiums or other cost sharing requirements of the Program.
10(Source: P.A. 94-693, eff. 7-1-06; 95-985, eff. 6-1-09.)
 
11    (215 ILCS 170/35)
12    (Section scheduled to be repealed on July 1, 2016)
13    Sec. 35. Health care benefits for children.
14    (a) The Department shall purchase or provide health care
15benefits for eligible children that are identical to the
16benefits provided for children under the Illinois Children's
17Health Insurance Program Act, except for non-emergency
18transportation.
19    (b) As an alternative to the benefits set forth in
20subsection (a), and when cost-effective, the Department may
21offer families subsidies toward the cost of privately sponsored
22health insurance, including employer-sponsored health
23insurance.
24    (c) Notwithstanding clause (i) of subdivision (a)(3) of
25Section 20, the Department may consider offering, as an

 

 

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1alternative to the benefits set forth in subsection (a),
2partial coverage to children who are enrolled in a
3high-deductible private health insurance plan.
4    (d) Notwithstanding clause (i) of subdivision (a)(3) of
5Section 20, the Department may consider offering, as an
6alternative to the benefits set forth in subsection (a), a
7limited package of benefits to children in families who have
8private or employer-sponsored health insurance that does not
9cover certain benefits such as dental or vision benefits.
10    (e) The content and availability of benefits described in
11subsections (b), (c), and (d), and the terms of eligibility for
12those benefits, shall be at the Department's discretion and the
13Department's determination of efficacy and cost-effectiveness
14as a means of promoting retention of private or
15employer-sponsored health insurance.
16    (f) On and after July 1, 2012, the Department shall reduce
17any rate of reimbursement for services or other payments or
18alter any methodologies authorized by this Act or the Illinois
19Public Aid Code to reduce any rate of reimbursement for
20services or other payments in accordance with Section 5-5e of
21the Illinois Public Aid Code.
22(Source: P.A. 94-693, eff. 7-1-06.)
 
23    Section 75. The Illinois Public Aid Code is amended by
24changing Sections 3-1.2, 5-2, 5-4, 5-4.1, 5-4.2, 5-5, 5-5.02,
255-5.05, 5-5.2, 5-5.3, 5-5.4, 5-5.4e, 5-5.5, 5-5.8b, 5-5.12,

 

 

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15-5.17, 5-5.20, 5-5.23, 5-5.24, 5-5.25, 5-16.7, 5-16.7a,
25-16.8, 5-16.9, 5-17, 5-19, 5-24, 5-30, 5A-1, 5A-2, 5A-3, 5A-4,
35A-5, 5A-6, 5A-8, 5A-10, 5A-12.2, 5A-14, 6-11, 11-13, 11-26,
412-4.25, 12-4.38, 12-4.39, 12-10.5, 12-13.1, 14-8, and 15-1 and
5by adding Sections 5-2b, 5-2.1d, 5-5e, 5-5e.1, 5-5f, 5A-15,
611-5.2, 11-5.3, and 14-11 as follows:
 
7    (305 ILCS 5/3-1.2)  (from Ch. 23, par. 3-1.2)
8    Sec. 3-1.2. Need. Income available to the person, when
9added to contributions in money, substance, or services from
10other sources, including contributions from legally
11responsible relatives, must be insufficient to equal the grant
12amount established by Department regulation for such person.
13    In determining earned income to be taken into account,
14consideration shall be given to any expenses reasonably
15attributable to the earning of such income. If federal law or
16regulations permit or require exemption of earned or other
17income and resources, the Illinois Department shall provide by
18rule and regulation that the amount of income to be disregarded
19be increased (1) to the maximum extent so required and (2) to
20the maximum extent permitted by federal law or regulation in
21effect as of the date this Amendatory Act becomes law. The
22Illinois Department may also provide by rule and regulation
23that the amount of resources to be disregarded be increased to
24the maximum extent so permitted or required. Subject to federal
25approval, resources (for example, land, buildings, equipment,

 

 

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1supplies, or tools), including farmland property and personal
2property used in the income-producing operations related to the
3farmland (for example, equipment and supplies, motor vehicles,
4or tools), necessary for self-support, up to $6,000 of the
5person's equity in the income-producing property, provided
6that the property produces a net annual income of at least 6%
7of the excluded equity value of the property, are exempt.
8Equity value in excess of $6,000 shall not be excluded if the
9activity produces income that is less than 6% of the exempt
10equity due to reasons beyond the person's control (for example,
11the person's illness or crop failure) and there is a reasonable
12expectation that the property will again produce income equal
13to or greater than 6% of the equity value (for example, a
14medical prognosis that the person is expected to respond to
15treatment or that drought-resistant corn will be planted). If
16the person owns more than one piece of property and each
17produces income, each piece of property shall be looked at to
18determine whether the 6% rule is met, and then the amounts of
19the person's equity in all of those properties shall be totaled
20to determine whether the total equity is $6,000 or less. The
21total equity value of all properties that is exempt shall be
22limited to $6,000.
23    In determining the resources of an individual or any
24dependents, the Department shall exclude from consideration
25the value of funeral and burial spaces, grave markers and other
26funeral and burial merchandise, funeral and burial insurance

 

 

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1the proceeds of which can only be used to pay the funeral and
2burial expenses of the insured and funds specifically set aside
3for the funeral and burial arrangements of the individual or
4his or her dependents, including prepaid funeral and burial
5plans, to the same extent that such items are excluded from
6consideration under the federal Supplemental Security Income
7program (SSI).
8    Prepaid funeral or burial contracts are exempt to the
9following extent:
10        (1) Funds in a revocable prepaid funeral or burial
11    contract are exempt up to $1,500, except that any portion
12    of a contract that clearly represents the purchase of
13    burial space, as that term is defined for purposes of the
14    Supplemental Security Income program, is exempt regardless
15    of value.
16        (2) Funds in an irrevocable prepaid funeral or burial
17    contract are exempt up to $5,874, except that any portion
18    of a contract that clearly represents the purchase of
19    burial space, as that term is defined for purposes of the
20    Supplemental Security Income program, is exempt regardless
21    of value. This amount shall be adjusted annually for any
22    increase in the Consumer Price Index. The amount exempted
23    shall be limited to the price of the funeral goods and
24    services to be provided upon death. The contract must
25    provide a complete description of the funeral goods and
26    services to be provided and the price thereof. Any amount

 

 

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1    in the contract not so specified shall be treated as a
2    transfer of assets for less than fair market value.
3        (3) A prepaid, guaranteed-price funeral or burial
4    contract, funded by an irrevocable assignment of a person's
5    life insurance policy to a trust, is exempt. The amount
6    exempted shall be limited to the amount of the insurance
7    benefit designated for the cost of the funeral goods and
8    services to be provided upon the person's death. The
9    contract must provide a complete description of the funeral
10    goods and services to be provided and the price thereof.
11    Any amount in the contract not so specified shall be
12    treated as a transfer of assets for less than fair market
13    value. The trust must include a statement that, upon the
14    death of the person, the State will receive all amounts
15    remaining in the trust, including any remaining payable
16    proceeds under the insurance policy up to an amount equal
17    to the total medical assistance paid on behalf of the
18    person. The trust is responsible for ensuring that the
19    provider of funeral services under the contract receives
20    the proceeds of the policy when it provides the funeral
21    goods and services specified under the contract. The
22    irrevocable assignment of ownership of the insurance
23    policy must be acknowledged by the insurance company.
24    Notwithstanding any other provision of this Code to the
25contrary, an irrevocable trust containing the resources of a
26person who is determined to have a disability shall be

 

 

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1considered exempt from consideration. Such trust must be
2established and managed by a non-profit association that pools
3funds but maintains a separate account for each beneficiary.
4The trust may be established by the person, a parent,
5grandparent, legal guardian, or court. It must be established
6for the sole benefit of the person and language contained in
7the trust shall stipulate that any amount remaining in the
8trust (up to the amount expended by the Department on medical
9assistance) that is not retained by the trust for reasonable
10administrative costs related to wrapping up the affairs of the
11subaccount shall be paid to the Department upon the death of
12the person. After a person reaches age 65, any funding by or on
13behalf of the person to the trust shall be treated as a
14transfer of assets for less than fair market value unless the
15person is a ward of a county public guardian or the State
16guardian pursuant to Section 13-5 of the Probate Act of 1975 or
17Section 30 of the Guardianship and Advocacy Act and lives in
18the community, or the person is a ward of a county public
19guardian or the State guardian pursuant to Section 13-5 of the
20Probate Act of 1975 or Section 30 of the Guardianship and
21Advocacy Act and a court has found that any expenditures from
22the trust will maintain or enhance the person's quality of
23life. If the trust contains proceeds from a personal injury
24settlement, any Department charge must be satisfied in order
25for the transfer to the trust to be treated as a transfer for
26fair market value.

 

 

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1    The homestead shall be exempt from consideration except to
2the extent that it meets the income and shelter needs of the
3person. "Homestead" means the dwelling house and contiguous
4real estate owned and occupied by the person, regardless of its
5value. Subject to federal approval, a person shall not be
6eligible for long-term care services, however, if the person's
7equity interest in his or her homestead exceeds the minimum
8home equity as allowed and increased annually under federal
9law. Subject to federal approval, on and after the effective
10date of this amendatory Act of the 97th General Assembly,
11homestead property transferred to a trust shall no longer be
12considered homestead property.
13    Occasional or irregular gifts in cash, goods or services
14from persons who are not legally responsible relatives which
15are of nominal value or which do not have significant effect in
16meeting essential requirements shall be disregarded. The
17eligibility of any applicant for or recipient of public aid
18under this Article is not affected by the payment of any grant
19under the "Senior Citizens and Disabled Persons Property Tax
20Relief and Pharmaceutical Assistance Act" or any distributions
21or items of income described under subparagraph (X) of
22paragraph (2) of subsection (a) of Section 203 of the Illinois
23Income Tax Act.
24    The Illinois Department may, after appropriate
25investigation, establish and implement a consolidated standard
26to determine need and eligibility for and amount of benefits

 

 

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1under this Article or a uniform cash supplement to the federal
2Supplemental Security Income program for all or any part of the
3then current recipients under this Article; provided, however,
4that the establishment or implementation of such a standard or
5supplement shall not result in reductions in benefits under
6this Article for the then current recipients of such benefits.
7(Source: P.A. 91-676, eff. 12-23-99.)
 
8    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
9    Sec. 5-2. Classes of Persons Eligible. Medical assistance
10under this Article shall be available to any of the following
11classes of persons in respect to whom a plan for coverage has
12been submitted to the Governor by the Illinois Department and
13approved by him:
14        1. Recipients of basic maintenance grants under
15    Articles III and IV.
16        2. Persons otherwise eligible for basic maintenance
17    under Articles III and IV, excluding any eligibility
18    requirements that are inconsistent with any federal law or
19    federal regulation, as interpreted by the U.S. Department
20    of Health and Human Services, but who fail to qualify
21    thereunder on the basis of need or who qualify but are not
22    receiving basic maintenance under Article IV, and who have
23    insufficient income and resources to meet the costs of
24    necessary medical care, including but not limited to the
25    following:

 

 

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1            (a) All persons otherwise eligible for basic
2        maintenance under Article III but who fail to qualify
3        under that Article on the basis of need and who meet
4        either of the following requirements:
5                (i) their income, as determined by the
6            Illinois Department in accordance with any federal
7            requirements, is equal to or less than 70% in
8            fiscal year 2001, equal to or less than 85% in
9            fiscal year 2002 and until a date to be determined
10            by the Department by rule, and equal to or less
11            than 100% beginning on the date determined by the
12            Department by rule, of the nonfarm income official
13            poverty line, as defined by the federal Office of
14            Management and Budget and revised annually in
15            accordance with Section 673(2) of the Omnibus
16            Budget Reconciliation Act of 1981, applicable to
17            families of the same size; or
18                (ii) their income, after the deduction of
19            costs incurred for medical care and for other types
20            of remedial care, is equal to or less than 70% in
21            fiscal year 2001, equal to or less than 85% in
22            fiscal year 2002 and until a date to be determined
23            by the Department by rule, and equal to or less
24            than 100% beginning on the date determined by the
25            Department by rule, of the nonfarm income official
26            poverty line, as defined in item (i) of this

 

 

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1            subparagraph (a).
2            (b) All persons who, excluding any eligibility
3        requirements that are inconsistent with any federal
4        law or federal regulation, as interpreted by the U.S.
5        Department of Health and Human Services, would be
6        determined eligible for such basic maintenance under
7        Article IV by disregarding the maximum earned income
8        permitted by federal law.
9        3. Persons who would otherwise qualify for Aid to the
10    Medically Indigent under Article VII.
11        4. Persons not eligible under any of the preceding
12    paragraphs who fall sick, are injured, or die, not having
13    sufficient money, property or other resources to meet the
14    costs of necessary medical care or funeral and burial
15    expenses.
16        5.(a) Women during pregnancy, after the fact of
17    pregnancy has been determined by medical diagnosis, and
18    during the 60-day period beginning on the last day of the
19    pregnancy, together with their infants and children born
20    after September 30, 1983, whose income and resources are
21    insufficient to meet the costs of necessary medical care to
22    the maximum extent possible under Title XIX of the Federal
23    Social Security Act.
24        (b) The Illinois Department and the Governor shall
25    provide a plan for coverage of the persons eligible under
26    paragraph 5(a) by April 1, 1990. Such plan shall provide

 

 

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1    ambulatory prenatal care to pregnant women during a
2    presumptive eligibility period and establish an income
3    eligibility standard that is equal to 133% of the nonfarm
4    income official poverty line, as defined by the federal
5    Office of Management and Budget and revised annually in
6    accordance with Section 673(2) of the Omnibus Budget
7    Reconciliation Act of 1981, applicable to families of the
8    same size, provided that costs incurred for medical care
9    are not taken into account in determining such income
10    eligibility.
11        (c) The Illinois Department may conduct a
12    demonstration in at least one county that will provide
13    medical assistance to pregnant women, together with their
14    infants and children up to one year of age, where the
15    income eligibility standard is set up to 185% of the
16    nonfarm income official poverty line, as defined by the
17    federal Office of Management and Budget. The Illinois
18    Department shall seek and obtain necessary authorization
19    provided under federal law to implement such a
20    demonstration. Such demonstration may establish resource
21    standards that are not more restrictive than those
22    established under Article IV of this Code.
23        6. Persons under the age of 18 who fail to qualify as
24    dependent under Article IV and who have insufficient income
25    and resources to meet the costs of necessary medical care
26    to the maximum extent permitted under Title XIX of the

 

 

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1    Federal Social Security Act.
2        7. (Blank). Persons who are under 21 years of age and
3    would qualify as disabled as defined under the Federal
4    Supplemental Security Income Program, provided medical
5    service for such persons would be eligible for Federal
6    Financial Participation, and provided the Illinois
7    Department determines that:
8            (a) the person requires a level of care provided by
9        a hospital, skilled nursing facility, or intermediate
10        care facility, as determined by a physician licensed to
11        practice medicine in all its branches;
12            (b) it is appropriate to provide such care outside
13        of an institution, as determined by a physician
14        licensed to practice medicine in all its branches;
15            (c) the estimated amount which would be expended
16        for care outside the institution is not greater than
17        the estimated amount which would be expended in an
18        institution.
19        8. Persons who become ineligible for basic maintenance
20    assistance under Article IV of this Code in programs
21    administered by the Illinois Department due to employment
22    earnings and persons in assistance units comprised of
23    adults and children who become ineligible for basic
24    maintenance assistance under Article VI of this Code due to
25    employment earnings. The plan for coverage for this class
26    of persons shall:

 

 

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1            (a) extend the medical assistance coverage for up
2        to 12 months following termination of basic
3        maintenance assistance; and
4            (b) offer persons who have initially received 6
5        months of the coverage provided in paragraph (a) above,
6        the option of receiving an additional 6 months of
7        coverage, subject to the following:
8                (i) such coverage shall be pursuant to
9            provisions of the federal Social Security Act;
10                (ii) such coverage shall include all services
11            covered while the person was eligible for basic
12            maintenance assistance;
13                (iii) no premium shall be charged for such
14            coverage; and
15                (iv) such coverage shall be suspended in the
16            event of a person's failure without good cause to
17            file in a timely fashion reports required for this
18            coverage under the Social Security Act and
19            coverage shall be reinstated upon the filing of
20            such reports if the person remains otherwise
21            eligible.
22        9. Persons with acquired immunodeficiency syndrome
23    (AIDS) or with AIDS-related conditions with respect to whom
24    there has been a determination that but for home or
25    community-based services such individuals would require
26    the level of care provided in an inpatient hospital,

 

 

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1    skilled nursing facility or intermediate care facility the
2    cost of which is reimbursed under this Article. Assistance
3    shall be provided to such persons to the maximum extent
4    permitted under Title XIX of the Federal Social Security
5    Act.
6        10. Participants in the long-term care insurance
7    partnership program established under the Illinois
8    Long-Term Care Partnership Program Act who meet the
9    qualifications for protection of resources described in
10    Section 15 of that Act.
11        11. Persons with disabilities who are employed and
12    eligible for Medicaid, pursuant to Section
13    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
14    subject to federal approval, persons with a medically
15    improved disability who are employed and eligible for
16    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
17    the Social Security Act, as provided by the Illinois
18    Department by rule. In establishing eligibility standards
19    under this paragraph 11, the Department shall, subject to
20    federal approval:
21            (a) set the income eligibility standard at not
22        lower than 350% of the federal poverty level;
23            (b) exempt retirement accounts that the person
24        cannot access without penalty before the age of 59 1/2,
25        and medical savings accounts established pursuant to
26        26 U.S.C. 220;

 

 

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1            (c) allow non-exempt assets up to $25,000 as to
2        those assets accumulated during periods of eligibility
3        under this paragraph 11; and
4            (d) continue to apply subparagraphs (b) and (c) in
5        determining the eligibility of the person under this
6        Article even if the person loses eligibility under this
7        paragraph 11.
8        12. Subject to federal approval, persons who are
9    eligible for medical assistance coverage under applicable
10    provisions of the federal Social Security Act and the
11    federal Breast and Cervical Cancer Prevention and
12    Treatment Act of 2000. Those eligible persons are defined
13    to include, but not be limited to, the following persons:
14            (1) persons who have been screened for breast or
15        cervical cancer under the U.S. Centers for Disease
16        Control and Prevention Breast and Cervical Cancer
17        Program established under Title XV of the federal
18        Public Health Services Act in accordance with the
19        requirements of Section 1504 of that Act as
20        administered by the Illinois Department of Public
21        Health; and
22            (2) persons whose screenings under the above
23        program were funded in whole or in part by funds
24        appropriated to the Illinois Department of Public
25        Health for breast or cervical cancer screening.
26        "Medical assistance" under this paragraph 12 shall be

 

 

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1    identical to the benefits provided under the State's
2    approved plan under Title XIX of the Social Security Act.
3    The Department must request federal approval of the
4    coverage under this paragraph 12 within 30 days after the
5    effective date of this amendatory Act of the 92nd General
6    Assembly.
7        In addition to the persons who are eligible for medical
8    assistance pursuant to subparagraphs (1) and (2) of this
9    paragraph 12, and to be paid from funds appropriated to the
10    Department for its medical programs, any uninsured person
11    as defined by the Department in rules residing in Illinois
12    who is younger than 65 years of age, who has been screened
13    for breast and cervical cancer in accordance with standards
14    and procedures adopted by the Department of Public Health
15    for screening, and who is referred to the Department by the
16    Department of Public Health as being in need of treatment
17    for breast or cervical cancer is eligible for medical
18    assistance benefits that are consistent with the benefits
19    provided to those persons described in subparagraphs (1)
20    and (2). Medical assistance coverage for the persons who
21    are eligible under the preceding sentence is not dependent
22    on federal approval, but federal moneys may be used to pay
23    for services provided under that coverage upon federal
24    approval.
25        13. Subject to appropriation and to federal approval,
26    persons living with HIV/AIDS who are not otherwise eligible

 

 

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1    under this Article and who qualify for services covered
2    under Section 5-5.04 as provided by the Illinois Department
3    by rule.
4        14. Subject to the availability of funds for this
5    purpose, the Department may provide coverage under this
6    Article to persons who reside in Illinois who are not
7    eligible under any of the preceding paragraphs and who meet
8    the income guidelines of paragraph 2(a) of this Section and
9    (i) have an application for asylum pending before the
10    federal Department of Homeland Security or on appeal before
11    a court of competent jurisdiction and are represented
12    either by counsel or by an advocate accredited by the
13    federal Department of Homeland Security and employed by a
14    not-for-profit organization in regard to that application
15    or appeal, or (ii) are receiving services through a
16    federally funded torture treatment center. Medical
17    coverage under this paragraph 14 may be provided for up to
18    24 continuous months from the initial eligibility date so
19    long as an individual continues to satisfy the criteria of
20    this paragraph 14. If an individual has an appeal pending
21    regarding an application for asylum before the Department
22    of Homeland Security, eligibility under this paragraph 14
23    may be extended until a final decision is rendered on the
24    appeal. The Department may adopt rules governing the
25    implementation of this paragraph 14.
26        15. Family Care Eligibility.

 

 

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1            (a) On and after July 1, 2012 Through December 31,
2        2013, a caretaker relative who is 19 years of age or
3        older when countable income is at or below 133% 185% of
4        the Federal Poverty Level Guidelines, as published
5        annually in the Federal Register, for the appropriate
6        family size. Beginning January 1, 2014, a caretaker
7        relative who is 19 years of age or older when countable
8        income is at or below 133% of the Federal Poverty Level
9        Guidelines, as published annually in the Federal
10        Register, for the appropriate family size. A person may
11        not spend down to become eligible under this paragraph
12        15.
13            (b) Eligibility shall be reviewed annually.
14            (c) (Blank). Caretaker relatives enrolled under
15        this paragraph 15 in families with countable income
16        above 150% and at or below 185% of the Federal Poverty
17        Level Guidelines shall be counted as family members and
18        pay premiums as established under the Children's
19        Health Insurance Program Act.
20            (d) (Blank). Premiums shall be billed by and
21        payable to the Department or its authorized agent, on a
22        monthly basis.
23            (e) (Blank). The premium due date is the last day
24        of the month preceding the month of coverage.
25            (f) (Blank). Individuals shall have a grace period
26        through 60 days of coverage to pay the premium.

 

 

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1            (g) (Blank). Failure to pay the full monthly
2        premium by the last day of the grace period shall
3        result in termination of coverage.
4            (h) (Blank). Partial premium payments shall not be
5        refunded.
6            (i) Following termination of an individual's
7        coverage under this paragraph 15, the individual must
8        be determined eligible before the person can be
9        re-enrolled. following action is required before the
10        individual can be re-enrolled:
11                (1) A new application must be completed and the
12            individual must be determined otherwise eligible.
13                (2) There must be full payment of premiums due
14            under this Code, the Children's Health Insurance
15            Program Act, the Covering ALL KIDS Health
16            Insurance Act, or any other healthcare program
17            administered by the Department for periods in
18            which a premium was owed and not paid for the
19            individual.
20                (3) The first month's premium must be paid if
21            there was an unpaid premium on the date the
22            individual's previous coverage was canceled.
23        The Department is authorized to implement the
24    provisions of this amendatory Act of the 95th General
25    Assembly by adopting the medical assistance rules in effect
26    as of October 1, 2007, at 89 Ill. Admin. Code 125, and at

 

 

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1    89 Ill. Admin. Code 120.32 along with only those changes
2    necessary to conform to federal Medicaid requirements,
3    federal laws, and federal regulations, including but not
4    limited to Section 1931 of the Social Security Act (42
5    U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department
6    of Health and Human Services, and the countable income
7    eligibility standard authorized by this paragraph 15. The
8    Department may not otherwise adopt any rule to implement
9    this increase except as authorized by law, to meet the
10    eligibility standards authorized by the federal government
11    in the Medicaid State Plan or the Title XXI Plan, or to
12    meet an order from the federal government or any court.
13        16. Subject to appropriation, uninsured persons who
14    are not otherwise eligible under this Section who have been
15    certified and referred by the Department of Public Health
16    as having been screened and found to need diagnostic
17    evaluation or treatment, or both diagnostic evaluation and
18    treatment, for prostate or testicular cancer. For the
19    purposes of this paragraph 16, uninsured persons are those
20    who do not have creditable coverage, as defined under the
21    Health Insurance Portability and Accountability Act, or
22    have otherwise exhausted any insurance benefits they may
23    have had, for prostate or testicular cancer diagnostic
24    evaluation or treatment, or both diagnostic evaluation and
25    treatment. To be eligible, a person must furnish a Social
26    Security number. A person's assets are exempt from

 

 

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1    consideration in determining eligibility under this
2    paragraph 16. Such persons shall be eligible for medical
3    assistance under this paragraph 16 for so long as they need
4    treatment for the cancer. A person shall be considered to
5    need treatment if, in the opinion of the person's treating
6    physician, the person requires therapy directed toward
7    cure or palliation of prostate or testicular cancer,
8    including recurrent metastatic cancer that is a known or
9    presumed complication of prostate or testicular cancer and
10    complications resulting from the treatment modalities
11    themselves. Persons who require only routine monitoring
12    services are not considered to need treatment. "Medical
13    assistance" under this paragraph 16 shall be identical to
14    the benefits provided under the State's approved plan under
15    Title XIX of the Social Security Act. Notwithstanding any
16    other provision of law, the Department (i) does not have a
17    claim against the estate of a deceased recipient of
18    services under this paragraph 16 and (ii) does not have a
19    lien against any homestead property or other legal or
20    equitable real property interest owned by a recipient of
21    services under this paragraph 16.
22    In implementing the provisions of Public Act 96-20, the
23Department is authorized to adopt only those rules necessary,
24including emergency rules. Nothing in Public Act 96-20 permits
25the Department to adopt rules or issue a decision that expands
26eligibility for the FamilyCare Program to a person whose income

 

 

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1exceeds 185% of the Federal Poverty Level as determined from
2time to time by the U.S. Department of Health and Human
3Services, unless the Department is provided with express
4statutory authority.
5    The Illinois Department and the Governor shall provide a
6plan for coverage of the persons eligible under paragraph 7 as
7soon as possible after July 1, 1984.
8    The eligibility of any such person for medical assistance
9under this Article is not affected by the payment of any grant
10under the Senior Citizens and Disabled Persons Property Tax
11Relief and Pharmaceutical Assistance Act or any distributions
12or items of income described under subparagraph (X) of
13paragraph (2) of subsection (a) of Section 203 of the Illinois
14Income Tax Act. The Department shall by rule establish the
15amounts of assets to be disregarded in determining eligibility
16for medical assistance, which shall at a minimum equal the
17amounts to be disregarded under the Federal Supplemental
18Security Income Program. The amount of assets of a single
19person to be disregarded shall not be less than $2,000, and the
20amount of assets of a married couple to be disregarded shall
21not be less than $3,000.
22    To the extent permitted under federal law, any person found
23guilty of a second violation of Article VIIIA shall be
24ineligible for medical assistance under this Article, as
25provided in Section 8A-8.
26    The eligibility of any person for medical assistance under

 

 

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1this Article shall not be affected by the receipt by the person
2of donations or benefits from fundraisers held for the person
3in cases of serious illness, as long as neither the person nor
4members of the person's family have actual control over the
5donations or benefits or the disbursement of the donations or
6benefits.
7(Source: P.A. 96-20, eff. 6-30-09; 96-181, eff. 8-10-09;
896-328, eff. 8-11-09; 96-567, eff. 1-1-10; 96-1000, eff.
97-2-10; 96-1123, eff. 1-1-11; 96-1270, eff. 7-26-10; 97-48,
10eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, eff. 8-12-11;
11revised 10-4-11.)
 
12    (305 ILCS 5/5-2b new)
13    Sec. 5-2b. Medically fragile and technology dependent
14children eligibility and program. Notwithstanding any other
15provision of law, on and after September 1, 2012, subject to
16federal approval, medical assistance under this Article shall
17be available to children who qualify as persons with a
18disability, as defined under the federal Supplemental Security
19Income program and who are medically fragile and technology
20dependent. The program shall allow eligible children to receive
21the medical assistance provided under this Article in the
22community, shall be limited to families with income up to 500%
23of the federal poverty level, and must maximize, to the fullest
24extent permissible under federal law, federal reimbursement
25and family cost-sharing, including co-pays, premiums, or any

 

 

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1other family contributions, except that the Department shall be
2permitted to incentivize the utilization of selected services
3through the use of cost-sharing adjustments. The Department
4shall establish the policies, procedures, standards, services,
5and criteria for this program by rule.
 
6    (305 ILCS 5/5-2.1d new)
7    Sec. 5-2.1d. Retroactive eligibility. An applicant for
8medical assistance may be eligible for up to 3 months prior to
9the date of application if the person would have been eligible
10for medical assistance at the time he or she received the
11services if he or she had applied, regardless of whether the
12individual is alive when the application for medical assistance
13is made. In determining financial eligibility for medical
14assistance for retroactive months, the Department shall
15consider the amount of income and resources and exemptions
16available to a person as of the first day of each of the
17backdated months for which eligibility is sought.
 
18    (305 ILCS 5/5-4)  (from Ch. 23, par. 5-4)
19    Sec. 5-4. Amount and nature of medical assistance.
20    (a) The amount and nature of medical assistance shall be
21determined by the County Departments in accordance with the
22standards, rules, and regulations of the Department of
23Healthcare and Family Services, with due regard to the
24requirements and conditions in each case, including

 

 

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1contributions available from legally responsible relatives.
2However, the amount and nature of such medical assistance shall
3not be affected by the payment of any grant under the Senior
4Citizens and Disabled Persons Property Tax Relief and
5Pharmaceutical Assistance Act or any distributions or items of
6income described under subparagraph (X) of paragraph (2) of
7subsection (a) of Section 203 of the Illinois Income Tax Act.
8The amount and nature of medical assistance shall not be
9affected by the receipt of donations or benefits from
10fundraisers in cases of serious illness, as long as neither the
11person nor members of the person's family have actual control
12over the donations or benefits or the disbursement of the
13donations or benefits.
14    In determining the income and resources assets available to
15the institutionalized spouse and to the community spouse, the
16Department of Healthcare and Family Services shall follow the
17procedures established by federal law. If an institutionalized
18spouse or community spouse refuses to comply with the
19requirements of Title XIX of the federal Social Security Act
20and the regulations duly promulgated thereunder by failing to
21provide the total value of assets, including income and
22resources, to the extent either the institutionalized spouse or
23community spouse has an ownership interest in them pursuant to
2442 U.S.C. 1396r-5, such refusal may result in the
25institutionalized spouse being denied eligibility and
26continuing to remain ineligible for the medical assistance

 

 

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1program based on failure to cooperate.
2    Subject to federal approval, the The community spouse
3resource allowance shall be established and maintained at the
4higher of $109,560 or the minimum maximum level permitted
5pursuant to Section 1924(f)(2) of the Social Security Act, as
6now or hereafter amended, or an amount set after a fair
7hearing, whichever is greater. The monthly maintenance
8allowance for the community spouse shall be established and
9maintained at the higher of $2,739 per month or the minimum
10maximum level permitted pursuant to Section 1924(d)(3)(C) of
11the Social Security Act, as now or hereafter amended, or an
12amount set after a fair hearing, whichever is greater. Subject
13to the approval of the Secretary of the United States
14Department of Health and Human Services, the provisions of this
15Section shall be extended to persons who but for the provision
16of home or community-based services under Section 4.02 of the
17Illinois Act on the Aging, would require the level of care
18provided in an institution, as is provided for in federal law.
19    (b) Spousal support for institutionalized spouses
20receiving medical assistance.
21        (i) The Department may seek support for an
22    institutionalized spouse, who has assigned his or her right
23    of support from his or her spouse to the State, from the
24    resources and income available to the community spouse.
25        (ii) The Department may bring an action in the circuit
26    court to establish support orders or itself establish

 

 

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1    administrative support orders by any means and procedures
2    authorized in this Code, as applicable, except that the
3    standard and regulations for determining ability to
4    support in Section 10-3 shall not limit the amount of
5    support that may be ordered.
6        (iii) Proceedings may be initiated to obtain support,
7    or for the recovery of aid granted during the period such
8    support was not provided, or both, for the obtainment of
9    support and the recovery of the aid provided. Proceedings
10    for the recovery of aid may be taken separately or they may
11    be consolidated with actions to obtain support. Such
12    proceedings may be brought in the name of the person or
13    persons requiring support or may be brought in the name of
14    the Department, as the case requires.
15        (iv) The orders for the payment of moneys for the
16    support of the person shall be just and equitable and may
17    direct payment thereof for such period or periods of time
18    as the circumstances require, including support for a
19    period before the date the order for support is entered. In
20    no event shall the orders reduce the community spouse
21    resource allowance below the level established in
22    subsection (a) of this Section or an amount set after a
23    fair hearing, whichever is greater, or reduce the monthly
24    maintenance allowance for the community spouse below the
25    level permitted pursuant to subsection (a) of this Section.
26    The Department of Human Services shall notify in writing

 

 

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1each institutionalized spouse who is a recipient of medical
2assistance under this Article, and each such person's community
3spouse, of the changes in treatment of income and resources,
4including provisions for protecting income for a community
5spouse and permitting the transfer of resources to a community
6spouse, required by enactment of the federal Medicare
7Catastrophic Coverage Act of 1988 (Public Law 100-360). The
8notification shall be in language likely to be easily
9understood by those persons. The Department of Human Services
10also shall reassess the amount of medical assistance for which
11each such recipient is eligible as a result of the enactment of
12that federal Act, whether or not a recipient requests such a
13reassessment.
14(Source: P.A. 95-331, eff. 8-21-07.)
 
15    (305 ILCS 5/5-4.1)  (from Ch. 23, par. 5-4.1)
16    Sec. 5-4.1. Co-payments. The Department may by rule provide
17that recipients under any Article of this Code shall pay a fee
18as a co-payment for services. Co-payments shall be maximized to
19the extent permitted by federal law, except that the Department
20shall impose a co-pay of $2 on generic drugs. Provided,
21however, that any such rule must provide that no co-payment
22requirement can exist for renal dialysis, radiation therapy,
23cancer chemotherapy, or insulin, and other products necessary
24on a recurring basis, the absence of which would be life
25threatening, or where co-payment expenditures for required

 

 

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1services and/or medications for chronic diseases that the
2Illinois Department shall by rule designate shall cause an
3extensive financial burden on the recipient, and provided no
4co-payment shall exist for emergency room encounters which are
5for medical emergencies. The Department shall seek approval of
6a State plan amendment that allows pharmacies to refuse to
7dispense drugs in circumstances where the recipient does not
8pay the required co-payment. In the event the State plan
9amendment is rejected, co-payments may not exceed $3 for brand
10name drugs, $1 for other pharmacy services other than for
11generic drugs, and $2 for physician services, dental services,
12optical services and supplies, chiropractic services, podiatry
13services, and encounter rate clinic services. There shall be no
14co-payment for generic drugs. Co-payments may not exceed $10
15for emergency room use for a non-emergency situation as defined
16by the Department by rule and subject to federal approval.
17(Source: P.A. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11.)
 
18    (305 ILCS 5/5-4.2)  (from Ch. 23, par. 5-4.2)
19    Sec. 5-4.2. Ambulance services payments.
20    (a) For ambulance services provided to a recipient of aid
21under this Article on or after January 1, 1993, the Illinois
22Department shall reimburse ambulance service providers at
23rates calculated in accordance with this Section. It is the
24intent of the General Assembly to provide adequate
25reimbursement for ambulance services so as to ensure adequate

 

 

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1access to services for recipients of aid under this Article and
2to provide appropriate incentives to ambulance service
3providers to provide services in an efficient and
4cost-effective manner. Thus, it is the intent of the General
5Assembly that the Illinois Department implement a
6reimbursement system for ambulance services that, to the extent
7practicable and subject to the availability of funds
8appropriated by the General Assembly for this purpose, is
9consistent with the payment principles of Medicare. To ensure
10uniformity between the payment principles of Medicare and
11Medicaid, the Illinois Department shall follow, to the extent
12necessary and practicable and subject to the availability of
13funds appropriated by the General Assembly for this purpose,
14the statutes, laws, regulations, policies, procedures,
15principles, definitions, guidelines, and manuals used to
16determine the amounts paid to ambulance service providers under
17Title XVIII of the Social Security Act (Medicare).
18    (b) For ambulance services provided to a recipient of aid
19under this Article on or after January 1, 1996, the Illinois
20Department shall reimburse ambulance service providers based
21upon the actual distance traveled if a natural disaster,
22weather conditions, road repairs, or traffic congestion
23necessitates the use of a route other than the most direct
24route.
25    (c) For purposes of this Section, "ambulance services"
26includes medical transportation services provided by means of

 

 

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1an ambulance, medi-car, service car, or taxi.
2    (c-1) For purposes of this Section, "ground ambulance
3service" means medical transportation services that are
4described as ground ambulance services by the Centers for
5Medicare and Medicaid Services and provided in a vehicle that
6is licensed as an ambulance by the Illinois Department of
7Public Health pursuant to the Emergency Medical Services (EMS)
8Systems Act.
9    (c-2) For purposes of this Section, "ground ambulance
10service provider" means a vehicle service provider as described
11in the Emergency Medical Services (EMS) Systems Act that
12operates licensed ambulances for the purpose of providing
13emergency ambulance services, or non-emergency ambulance
14services, or both. For purposes of this Section, this includes
15both ambulance providers and ambulance suppliers as described
16by the Centers for Medicare and Medicaid Services.
17    (d) This Section does not prohibit separate billing by
18ambulance service providers for oxygen furnished while
19providing advanced life support services.
20    (e) Beginning with services rendered on or after July 1,
212008, all providers of non-emergency medi-car and service car
22transportation must certify that the driver and employee
23attendant, as applicable, have completed a safety program
24approved by the Department to protect both the patient and the
25driver, prior to transporting a patient. The provider must
26maintain this certification in its records. The provider shall

 

 

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1produce such documentation upon demand by the Department or its
2representative. Failure to produce documentation of such
3training shall result in recovery of any payments made by the
4Department for services rendered by a non-certified driver or
5employee attendant. Medi-car and service car providers must
6maintain legible documentation in their records of the driver
7and, as applicable, employee attendant that actually
8transported the patient. Providers must recertify all drivers
9and employee attendants every 3 years.
10    Notwithstanding the requirements above, any public
11transportation provider of medi-car and service car
12transportation that receives federal funding under 49 U.S.C.
135307 and 5311 need not certify its drivers and employee
14attendants under this Section, since safety training is already
15federally mandated.
16    (f) With respect to any policy or program administered by
17the Department or its agent regarding approval of non-emergency
18medical transportation by ground ambulance service providers,
19including, but not limited to, the Non-Emergency
20Transportation Services Prior Approval Program (NETSPAP), the
21Department shall establish by rule a process by which ground
22ambulance service providers of non-emergency medical
23transportation may appeal any decision by the Department or its
24agent for which no denial was received prior to the time of
25transport that either (i) denies a request for approval for
26payment of non-emergency transportation by means of ground

 

 

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1ambulance service or (ii) grants a request for approval of
2non-emergency transportation by means of ground ambulance
3service at a level of service that entitles the ground
4ambulance service provider to a lower level of compensation
5from the Department than the ground ambulance service provider
6would have received as compensation for the level of service
7requested. The rule shall be filed by December 15, 2012
8established within 12 months after the effective date of this
9amendatory Act of the 97th General Assembly and shall provide
10that, for any decision rendered by the Department or its agent
11on or after the date the rule takes effect, the ground
12ambulance service provider shall have 60 days from the date the
13decision is received to file an appeal. The rule established by
14the Department shall be, insofar as is practical, consistent
15with the Illinois Administrative Procedure Act. The Director's
16decision on an appeal under this Section shall be a final
17administrative decision subject to review under the
18Administrative Review Law.
19    (g) Whenever a patient covered by a medical assistance
20program under this Code or by another medical program
21administered by the Department is being discharged from a
22facility, a physician discharge order as described in this
23Section shall be required for each patient whose discharge
24requires medically supervised ground ambulance services.
25Facilities shall develop procedures for a physician with
26medical staff privileges to provide a written and signed

 

 

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1physician discharge order. The physician discharge order shall
2specify the level of ground ambulance services needed and
3complete a medical certification establishing the criteria for
4approval of non-emergency ambulance transportation, as
5published by the Department of Healthcare and Family Services,
6that is met by the patient. This order and the medical
7certification shall be completed prior to ordering an ambulance
8service and prior to patient discharge.
9    Pursuant to subsection (E) of Section 12-4.25 of this Code,
10the Department is entitled to recover overpayments paid to a
11provider or vendor, including, but not limited to, from the
12discharging physician, the discharging facility, and the
13ground ambulance service provider, in instances where a
14non-emergency ground ambulance service is rendered as the
15result of improper or false certification.
16    (h) On and after July 1, 2012, the Department shall reduce
17any rate of reimbursement for services or other payments or
18alter any methodologies authorized by this Code to reduce any
19rate of reimbursement for services or other payments in
20accordance with Section 5-5e.
21(Source: P.A. 97-584, eff. 8-26-11.)
 
22    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
23    Sec. 5-5. Medical services. The Illinois Department, by
24rule, shall determine the quantity and quality of and the rate
25of reimbursement for the medical assistance for which payment

 

 

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1will be authorized, and the medical services to be provided,
2which may include all or part of the following: (1) inpatient
3hospital services; (2) outpatient hospital services; (3) other
4laboratory and X-ray services; (4) skilled nursing home
5services; (5) physicians' services whether furnished in the
6office, the patient's home, a hospital, a skilled nursing home,
7or elsewhere; (6) medical care, or any other type of remedial
8care furnished by licensed practitioners; (7) home health care
9services; (8) private duty nursing service; (9) clinic
10services; (10) dental services, including prevention and
11treatment of periodontal disease and dental caries disease for
12pregnant women, provided by an individual licensed to practice
13dentistry or dental surgery; for purposes of this item (10),
14"dental services" means diagnostic, preventive, or corrective
15procedures provided by or under the supervision of a dentist in
16the practice of his or her profession; (11) physical therapy
17and related services; (12) prescribed drugs, dentures, and
18prosthetic devices; and eyeglasses prescribed by a physician
19skilled in the diseases of the eye, or by an optometrist,
20whichever the person may select; (13) other diagnostic,
21screening, preventive, and rehabilitative services, for
22children and adults; (14) transportation and such other
23expenses as may be necessary; (15) medical treatment of sexual
24assault survivors, as defined in Section 1a of the Sexual
25Assault Survivors Emergency Treatment Act, for injuries
26sustained as a result of the sexual assault, including

 

 

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1examinations and laboratory tests to discover evidence which
2may be used in criminal proceedings arising from the sexual
3assault; (16) the diagnosis and treatment of sickle cell
4anemia; and (17) any other medical care, and any other type of
5remedial care recognized under the laws of this State, but not
6including abortions, or induced miscarriages or premature
7births, unless, in the opinion of a physician, such procedures
8are necessary for the preservation of the life of the woman
9seeking such treatment, or except an induced premature birth
10intended to produce a live viable child and such procedure is
11necessary for the health of the mother or her unborn child. The
12Illinois Department, by rule, shall prohibit any physician from
13providing medical assistance to anyone eligible therefor under
14this Code where such physician has been found guilty of
15performing an abortion procedure in a wilful and wanton manner
16upon a woman who was not pregnant at the time such abortion
17procedure was performed. The term "any other type of remedial
18care" shall include nursing care and nursing home service for
19persons who rely on treatment by spiritual means alone through
20prayer for healing.
21    Notwithstanding any other provision of this Section, a
22comprehensive tobacco use cessation program that includes
23purchasing prescription drugs or prescription medical devices
24approved by the Food and Drug Administration shall be covered
25under the medical assistance program under this Article for
26persons who are otherwise eligible for assistance under this

 

 

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1Article.
2    Notwithstanding any other provision of this Code, the
3Illinois Department may not require, as a condition of payment
4for any laboratory test authorized under this Article, that a
5physician's handwritten signature appear on the laboratory
6test order form. The Illinois Department may, however, impose
7other appropriate requirements regarding laboratory test order
8documentation.
9    On and after July 1, 2012, the The Department of Healthcare
10and Family Services may shall provide the following services to
11persons eligible for assistance under this Article who are
12participating in education, training or employment programs
13operated by the Department of Human Services as successor to
14the Department of Public Aid:
15        (1) dental services provided by or under the
16    supervision of a dentist; and
17        (2) eyeglasses prescribed by a physician skilled in the
18    diseases of the eye, or by an optometrist, whichever the
19    person may select.
20    Notwithstanding any other provision of this Code and
21subject to federal approval, the Department may adopt rules to
22allow a dentist who is volunteering his or her service at no
23cost to render dental services through an enrolled
24not-for-profit health clinic without the dentist personally
25enrolling as a participating provider in the medical assistance
26program. A not-for-profit health clinic shall include a public

 

 

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1health clinic or Federally Qualified Health Center or other
2enrolled provider, as determined by the Department, through
3which dental services covered under this Section are performed.
4The Department shall establish a process for payment of claims
5for reimbursement for covered dental services rendered under
6this provision.
7    The Illinois Department, by rule, may distinguish and
8classify the medical services to be provided only in accordance
9with the classes of persons designated in Section 5-2.
10    The Department of Healthcare and Family Services must
11provide coverage and reimbursement for amino acid-based
12elemental formulas, regardless of delivery method, for the
13diagnosis and treatment of (i) eosinophilic disorders and (ii)
14short bowel syndrome when the prescribing physician has issued
15a written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for women
2035 years of age or older who are eligible for medical
21assistance under this Article, as follows:
22        (A) A baseline mammogram for women 35 to 39 years of
23    age.
24        (B) An annual mammogram for women 40 years of age or
25    older.
26        (C) A mammogram at the age and intervals considered

 

 

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1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (D) A comprehensive ultrasound screening of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue, when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10    All screenings shall include a physical breast exam,
11instruction on self-examination and information regarding the
12frequency of self-examination and its value as a preventative
13tool. For purposes of this Section, "low-dose mammography"
14means the x-ray examination of the breast using equipment
15dedicated specifically for mammography, including the x-ray
16tube, filter, compression device, and image receptor, with an
17average radiation exposure delivery of less than one rad per
18breast for 2 views of an average size breast. The term also
19includes digital mammography.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

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1facilities, and doctors, including radiologists, to establish
2quality standards.
3    Subject to federal approval, the Department shall
4establish a rate methodology for mammography at federally
5qualified health centers and other encounter-rate clinics.
6These clinics or centers may also collaborate with other
7hospital-based mammography facilities.
8    The Department shall establish a methodology to remind
9women who are age-appropriate for screening mammography, but
10who have not received a mammogram within the previous 18
11months, of the importance and benefit of screening mammography.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. An evaluation of the
25pilot program shall be carried out measuring health outcomes
26and cost of care for those served by the pilot program compared

 

 

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1to similarly situated patients who are not served by the pilot
2program.
3    Any medical or health care provider shall immediately
4recommend, to any pregnant woman who is being provided prenatal
5services and is suspected of drug abuse or is addicted as
6defined in the Alcoholism and Other Drug Abuse and Dependency
7Act, referral to a local substance abuse treatment provider
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department of
14Human Services.
15    All medical providers providing medical assistance to
16pregnant women under this Code shall receive information from
17the Department on the availability of services under the Drug
18Free Families with a Future or any comparable program providing
19case management services for addicted women, including
20information on appropriate referrals for other social services
21that may be needed by addicted women in addition to treatment
22for addiction.
23    The Illinois Department, in cooperation with the
24Departments of Human Services (as successor to the Department
25of Alcoholism and Substance Abuse) and Public Health, through a
26public awareness campaign, may provide information concerning

 

 

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1treatment for alcoholism and drug abuse and addiction, prenatal
2health care, and other pertinent programs directed at reducing
3the number of drug-affected infants born to recipients of
4medical assistance.
5    Neither the Department of Healthcare and Family Services
6nor the Department of Human Services shall sanction the
7recipient solely on the basis of her substance abuse.
8    The Illinois Department shall establish such regulations
9governing the dispensing of health services under this Article
10as it shall deem appropriate. The Department should seek the
11advice of formal professional advisory committees appointed by
12the Director of the Illinois Department for the purpose of
13providing regular advice on policy and administrative matters,
14information dissemination and educational activities for
15medical and health care providers, and consistency in
16procedures to the Illinois Department.
17    Notwithstanding any other provision of law, a health care
18provider under the medical assistance program may elect, in
19lieu of receiving direct payment for services provided under
20that program, to participate in the State Employees Deferred
21Compensation Plan adopted under Article 24 of the Illinois
22Pension Code. A health care provider who elects to participate
23in the plan does not have a cause of action against the State
24for any damages allegedly suffered by the provider as a result
25of any delay by the State in crediting the amount of any
26contribution to the provider's plan account.

 

 

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1    The Illinois Department may develop and contract with
2Partnerships of medical providers to arrange medical services
3for persons eligible under Section 5-2 of this Code.
4Implementation of this Section may be by demonstration projects
5in certain geographic areas. The Partnership shall be
6represented by a sponsor organization. The Department, by rule,
7shall develop qualifications for sponsors of Partnerships.
8Nothing in this Section shall be construed to require that the
9sponsor organization be a medical organization.
10    The sponsor must negotiate formal written contracts with
11medical providers for physician services, inpatient and
12outpatient hospital care, home health services, treatment for
13alcoholism and substance abuse, and other services determined
14necessary by the Illinois Department by rule for delivery by
15Partnerships. Physician services must include prenatal and
16obstetrical care. The Illinois Department shall reimburse
17medical services delivered by Partnership providers to clients
18in target areas according to provisions of this Article and the
19Illinois Health Finance Reform Act, except that:
20        (1) Physicians participating in a Partnership and
21    providing certain services, which shall be determined by
22    the Illinois Department, to persons in areas covered by the
23    Partnership may receive an additional surcharge for such
24    services.
25        (2) The Department may elect to consider and negotiate
26    financial incentives to encourage the development of

 

 

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1    Partnerships and the efficient delivery of medical care.
2        (3) Persons receiving medical services through
3    Partnerships may receive medical and case management
4    services above the level usually offered through the
5    medical assistance program.
6    Medical providers shall be required to meet certain
7qualifications to participate in Partnerships to ensure the
8delivery of high quality medical services. These
9qualifications shall be determined by rule of the Illinois
10Department and may be higher than qualifications for
11participation in the medical assistance program. Partnership
12sponsors may prescribe reasonable additional qualifications
13for participation by medical providers, only with the prior
14written approval of the Illinois Department.
15    Nothing in this Section shall limit the free choice of
16practitioners, hospitals, and other providers of medical
17services by clients. In order to ensure patient freedom of
18choice, the Illinois Department shall immediately promulgate
19all rules and take all other necessary actions so that provided
20services may be accessed from therapeutically certified
21optometrists to the full extent of the Illinois Optometric
22Practice Act of 1987 without discriminating between service
23providers.
24    The Department shall apply for a waiver from the United
25States Health Care Financing Administration to allow for the
26implementation of Partnerships under this Section.

 

 

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1    The Illinois Department shall require health care
2providers to maintain records that document the medical care
3and services provided to recipients of Medical Assistance under
4this Article. Such records must be retained for a period of not
5less than 6 years from the date of service or as provided by
6applicable State law, whichever period is longer, except that
7if an audit is initiated within the required retention period
8then the records must be retained until the audit is completed
9and every exception is resolved. The Illinois Department shall
10require health care providers to make available, when
11authorized by the patient, in writing, the medical records in a
12timely fashion to other health care providers who are treating
13or serving persons eligible for Medical Assistance under this
14Article. All dispensers of medical services shall be required
15to maintain and retain business and professional records
16sufficient to fully and accurately document the nature, scope,
17details and receipt of the health care provided to persons
18eligible for medical assistance under this Code, in accordance
19with regulations promulgated by the Illinois Department. The
20rules and regulations shall require that proof of the receipt
21of prescription drugs, dentures, prosthetic devices and
22eyeglasses by eligible persons under this Section accompany
23each claim for reimbursement submitted by the dispenser of such
24medical services. No such claims for reimbursement shall be
25approved for payment by the Illinois Department without such
26proof of receipt, unless the Illinois Department shall have put

 

 

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1into effect and shall be operating a system of post-payment
2audit and review which shall, on a sampling basis, be deemed
3adequate by the Illinois Department to assure that such drugs,
4dentures, prosthetic devices and eyeglasses for which payment
5is being made are actually being received by eligible
6recipients. Within 90 days after the effective date of this
7amendatory Act of 1984, the Illinois Department shall establish
8a current list of acquisition costs for all prosthetic devices
9and any other items recognized as medical equipment and
10supplies reimbursable under this Article and shall update such
11list on a quarterly basis, except that the acquisition costs of
12all prescription drugs shall be updated no less frequently than
13every 30 days as required by Section 5-5.12.
14    The rules and regulations of the Illinois Department shall
15require that a written statement including the required opinion
16of a physician shall accompany any claim for reimbursement for
17abortions, or induced miscarriages or premature births. This
18statement shall indicate what procedures were used in providing
19such medical services.
20    The Illinois Department shall require all dispensers of
21medical services, other than an individual practitioner or
22group of practitioners, desiring to participate in the Medical
23Assistance program established under this Article to disclose
24all financial, beneficial, ownership, equity, surety or other
25interests in any and all firms, corporations, partnerships,
26associations, business enterprises, joint ventures, agencies,

 

 

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1institutions or other legal entities providing any form of
2health care services in this State under this Article.
3    The Illinois Department may require that all dispensers of
4medical services desiring to participate in the medical
5assistance program established under this Article disclose,
6under such terms and conditions as the Illinois Department may
7by rule establish, all inquiries from clients and attorneys
8regarding medical bills paid by the Illinois Department, which
9inquiries could indicate potential existence of claims or liens
10for the Illinois Department.
11    Enrollment of a vendor that provides non-emergency medical
12transportation, defined by the Department by rule, shall be
13subject to a provisional period and shall be conditional for
14one year 180 days. During the period of conditional enrollment
15that time, the Department of Healthcare and Family Services may
16terminate the vendor's eligibility to participate in, or may
17disenroll the vendor from, the medical assistance program
18without cause. Unless otherwise specified, such That
19termination of eligibility or disenrollment is not subject to
20the Department's hearing process. However, a disenrolled
21vendor may reapply without penalty.
22    The Department has the discretion to limit the conditional
23enrollment period for vendors based upon category of risk of
24the vendor.
25    Prior to enrollment and during the conditional enrollment
26period in the medical assistance program, all vendors shall be

 

 

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1subject to enhanced oversight, screening, and review based on
2the risk of fraud, waste, and abuse that is posed by the
3category of risk of the vendor. The Illinois Department shall
4establish the procedures for oversight, screening, and review,
5which may include, but need not be limited to: criminal and
6financial background checks; fingerprinting; license,
7certification, and authorization verifications; unscheduled or
8unannounced site visits; database checks; prepayment audit
9reviews; audits; payment caps; payment suspensions; and other
10screening as required by federal or State law.
11    The Department shall define or specify the following: (i)
12by provider notice, the "category of risk of the vendor" for
13each type of vendor, which shall take into account the level of
14screening applicable to a particular category of vendor under
15federal law and regulations; (ii) by rule or provider notice,
16the maximum length of the conditional enrollment period for
17each category of risk of the vendor; and (iii) by rule, the
18hearing rights, if any, afforded to a vendor in each category
19of risk of the vendor that is terminated or disenrolled during
20the conditional enrollment period.
21    To be eligible for payment consideration, a vendor's
22payment claim or bill, either as an initial claim or as a
23resubmitted claim following prior rejection, must be received
24by the Illinois Department, or its fiscal intermediary, no
25later than 180 days after the latest date on the claim on which
26medical goods or services were provided, with the following

 

 

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1exceptions:
2        (1) In the case of a provider whose enrollment is in
3    process by the Illinois Department, the 180-day period
4    shall not begin until the date on the written notice from
5    the Illinois Department that the provider enrollment is
6    complete.
7        (2) In the case of errors attributable to the Illinois
8    Department or any of its claims processing intermediaries
9    which result in an inability to receive, process, or
10    adjudicate a claim, the 180-day period shall not begin
11    until the provider has been notified of the error.
12        (3) In the case of a provider for whom the Illinois
13    Department initiates the monthly billing process.
14    For claims for services rendered during a period for which
15a recipient received retroactive eligibility, claims must be
16filed within 180 days after the Department determines the
17applicant is eligible. For claims for which the Illinois
18Department is not the primary payer, claims must be submitted
19to the Illinois Department within 180 days after the final
20adjudication by the primary payer.
21    In the case of long term care facilities, admission
22documents shall be submitted within 30 days of an admission to
23the facility through the Medical Electronic Data Interchange
24(MEDI) or the Recipient Eligibility Verification (REV) System,
25or shall be submitted directly to the Department of Human
26Services using required admission forms. Confirmation numbers

 

 

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1assigned to an accepted transaction shall be retained by a
2facility to verify timely submittal. Once an admission
3transaction has been completed, all resubmitted claims
4following prior rejection are subject to receipt no later than
5180 days after the admission transaction has been completed.
6    Claims that are not submitted and received in compliance
7with the foregoing requirements shall not be eligible for
8payment under the medical assistance program, and the State
9shall have no liability for payment of those claims.
10    To the extent consistent with applicable information and
11privacy, security, and disclosure laws, State and federal
12agencies and departments shall provide the Illinois Department
13access to confidential and other information and data necessary
14to perform eligibility and payment verifications and other
15Illinois Department functions. This includes, but is not
16limited to: information pertaining to licensure;
17certification; earnings; immigration status; citizenship; wage
18reporting; unearned and earned income; pension income;
19employment; supplemental security income; social security
20numbers; National Provider Identifier (NPI) numbers; the
21National Practitioner Data Bank (NPDB); program and agency
22exclusions; taxpayer identification numbers; tax delinquency;
23corporate information; and death records.
24    The Illinois Department shall enter into agreements with
25State agencies and departments, and is authorized to enter into
26agreements with federal agencies and departments, under which

 

 

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1such agencies and departments shall share data necessary for
2medical assistance program integrity functions and oversight.
3The Illinois Department shall develop, in cooperation with
4other State departments and agencies, and in compliance with
5applicable federal laws and regulations, appropriate and
6effective methods to share such data. At a minimum, and to the
7extent necessary to provide data sharing, the Illinois
8Department shall enter into agreements with State agencies and
9departments, and is authorized to enter into agreements with
10federal agencies and departments, including but not limited to:
11the Secretary of State; the Department of Revenue; the
12Department of Public Health; the Department of Human Services;
13and the Department of Financial and Professional Regulation.
14    Beginning in fiscal year 2013, the Illinois Department
15shall set forth a request for information to identify the
16benefits of a pre-payment, post-adjudication, and post-edit
17claims system with the goals of streamlining claims processing
18and provider reimbursement, reducing the number of pending or
19rejected claims, and helping to ensure a more transparent
20adjudication process through the utilization of: (i) provider
21data verification and provider screening technology; and (ii)
22clinical code editing; and (iii) pre-pay, pre- or
23post-adjudicated predictive modeling with an integrated case
24management system with link analysis. Such a request for
25information shall not be considered as a request for proposal
26or as an obligation on the part of the Illinois Department to

 

 

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1take any action or acquire any products or services.
2    The Illinois Department shall establish policies,
3procedures, standards and criteria by rule for the acquisition,
4repair and replacement of orthotic and prosthetic devices and
5durable medical equipment. Such rules shall provide, but not be
6limited to, the following services: (1) immediate repair or
7replacement of such devices by recipients without medical
8authorization; and (2) rental, lease, purchase or
9lease-purchase of durable medical equipment in a
10cost-effective manner, taking into consideration the
11recipient's medical prognosis, the extent of the recipient's
12needs, and the requirements and costs for maintaining such
13equipment. Subject to prior approval, such Such rules shall
14enable a recipient to temporarily acquire and use alternative
15or substitute devices or equipment pending repairs or
16replacements of any device or equipment previously authorized
17for such recipient by the Department.
18    The Department shall execute, relative to the nursing home
19prescreening project, written inter-agency agreements with the
20Department of Human Services and the Department on Aging, to
21effect the following: (i) intake procedures and common
22eligibility criteria for those persons who are receiving
23non-institutional services; and (ii) the establishment and
24development of non-institutional services in areas of the State
25where they are not currently available or are undeveloped; and
26(iii) notwithstanding any other provision of law, subject to

 

 

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1federal approval, on and after July 1, 2012, an increase in the
2determination of need (DON) scores from 29 to 37 for applicants
3for institutional and home and community-based long term care;
4if and only if federal approval is not granted, the Department
5may, in conjunction with other affected agencies, implement
6utilization controls or changes in benefit packages to
7effectuate a similar savings amount for this population; and
8(iv) no later than July 1, 2013, minimum level of care
9eligibility criteria for institutional and home and
10community-based long term care. In order to select the minimum
11level of care eligibility criteria, the Governor shall
12establish a workgroup that includes affected agency
13representatives and stakeholders representing the
14institutional and home and community-based long term care
15interests. This Section shall not restrict the Department from
16implementing lower level of care eligibility criteria for
17community-based services in circumstances where federal
18approval has been granted.
19    The Illinois Department shall develop and operate, in
20cooperation with other State Departments and agencies and in
21compliance with applicable federal laws and regulations,
22appropriate and effective systems of health care evaluation and
23programs for monitoring of utilization of health care services
24and facilities, as it affects persons eligible for medical
25assistance under this Code.
26    The Illinois Department shall report annually to the

 

 

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1General Assembly, no later than the second Friday in April of
21979 and each year thereafter, in regard to:
3        (a) actual statistics and trends in utilization of
4    medical services by public aid recipients;
5        (b) actual statistics and trends in the provision of
6    the various medical services by medical vendors;
7        (c) current rate structures and proposed changes in
8    those rate structures for the various medical vendors; and
9        (d) efforts at utilization review and control by the
10    Illinois Department.
11    The period covered by each report shall be the 3 years
12ending on the June 30 prior to the report. The report shall
13include suggested legislation for consideration by the General
14Assembly. The filing of one copy of the report with the
15Speaker, one copy with the Minority Leader and one copy with
16the Clerk of the House of Representatives, one copy with the
17President, one copy with the Minority Leader and one copy with
18the Secretary of the Senate, one copy with the Legislative
19Research Unit, and such additional copies with the State
20Government Report Distribution Center for the General Assembly
21as is required under paragraph (t) of Section 7 of the State
22Library Act shall be deemed sufficient to comply with this
23Section.
24    Rulemaking authority to implement Public Act 95-1045, if
25any, is conditioned on the rules being adopted in accordance
26with all provisions of the Illinois Administrative Procedure

 

 

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1Act and all rules and procedures of the Joint Committee on
2Administrative Rules; any purported rule not so adopted, for
3whatever reason, is unauthorized.
4    On and after July 1, 2012, the Department shall reduce any
5rate of reimbursement for services or other payments or alter
6any methodologies authorized by this Code to reduce any rate of
7reimbursement for services or other payments in accordance with
8Section 5-5e.
9(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
10eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
11eff. 1-1-12.)
 
12    (305 ILCS 5/5-5.02)  (from Ch. 23, par. 5-5.02)
13    Sec. 5-5.02. Hospital reimbursements.
14    (a) Reimbursement to Hospitals; July 1, 1992 through
15September 30, 1992. Notwithstanding any other provisions of
16this Code or the Illinois Department's Rules promulgated under
17the Illinois Administrative Procedure Act, reimbursement to
18hospitals for services provided during the period July 1, 1992
19through September 30, 1992, shall be as follows:
20        (1) For inpatient hospital services rendered, or if
21    applicable, for inpatient hospital discharges occurring,
22    on or after July 1, 1992 and on or before September 30,
23    1992, the Illinois Department shall reimburse hospitals
24    for inpatient services under the reimbursement
25    methodologies in effect for each hospital, and at the

 

 

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1    inpatient payment rate calculated for each hospital, as of
2    June 30, 1992. For purposes of this paragraph,
3    "reimbursement methodologies" means all reimbursement
4    methodologies that pertain to the provision of inpatient
5    hospital services, including, but not limited to, any
6    adjustments for disproportionate share, targeted access,
7    critical care access and uncompensated care, as defined by
8    the Illinois Department on June 30, 1992.
9        (2) For the purpose of calculating the inpatient
10    payment rate for each hospital eligible to receive
11    quarterly adjustment payments for targeted access and
12    critical care, as defined by the Illinois Department on
13    June 30, 1992, the adjustment payment for the period July
14    1, 1992 through September 30, 1992, shall be 25% of the
15    annual adjustment payments calculated for each eligible
16    hospital, as of June 30, 1992. The Illinois Department
17    shall determine by rule the adjustment payments for
18    targeted access and critical care beginning October 1,
19    1992.
20        (3) For the purpose of calculating the inpatient
21    payment rate for each hospital eligible to receive
22    quarterly adjustment payments for uncompensated care, as
23    defined by the Illinois Department on June 30, 1992, the
24    adjustment payment for the period August 1, 1992 through
25    September 30, 1992, shall be one-sixth of the total
26    uncompensated care adjustment payments calculated for each

 

 

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1    eligible hospital for the uncompensated care rate year, as
2    defined by the Illinois Department, ending on July 31,
3    1992. The Illinois Department shall determine by rule the
4    adjustment payments for uncompensated care beginning
5    October 1, 1992.
6    (b) Inpatient payments. For inpatient services provided on
7or after October 1, 1993, in addition to rates paid for
8hospital inpatient services pursuant to the Illinois Health
9Finance Reform Act, as now or hereafter amended, or the
10Illinois Department's prospective reimbursement methodology,
11or any other methodology used by the Illinois Department for
12inpatient services, the Illinois Department shall make
13adjustment payments, in an amount calculated pursuant to the
14methodology described in paragraph (c) of this Section, to
15hospitals that the Illinois Department determines satisfy any
16one of the following requirements:
17        (1) Hospitals that are described in Section 1923 of the
18    federal Social Security Act, as now or hereafter amended;
19    or
20        (2) Illinois hospitals that have a Medicaid inpatient
21    utilization rate which is at least one-half a standard
22    deviation above the mean Medicaid inpatient utilization
23    rate for all hospitals in Illinois receiving Medicaid
24    payments from the Illinois Department; or
25        (3) Illinois hospitals that on July 1, 1991 had a
26    Medicaid inpatient utilization rate, as defined in

 

 

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1    paragraph (h) of this Section, that was at least the mean
2    Medicaid inpatient utilization rate for all hospitals in
3    Illinois receiving Medicaid payments from the Illinois
4    Department and which were located in a planning area with
5    one-third or fewer excess beds as determined by the Health
6    Facilities and Services Review Board, and that, as of June
7    30, 1992, were located in a federally designated Health
8    Manpower Shortage Area; or
9        (4) Illinois hospitals that:
10            (A) have a Medicaid inpatient utilization rate
11        that is at least equal to the mean Medicaid inpatient
12        utilization rate for all hospitals in Illinois
13        receiving Medicaid payments from the Department; and
14            (B) also have a Medicaid obstetrical inpatient
15        utilization rate that is at least one standard
16        deviation above the mean Medicaid obstetrical
17        inpatient utilization rate for all hospitals in
18        Illinois receiving Medicaid payments from the
19        Department for obstetrical services; or
20        (5) Any children's hospital, which means a hospital
21    devoted exclusively to caring for children. A hospital
22    which includes a facility devoted exclusively to caring for
23    children shall be considered a children's hospital to the
24    degree that the hospital's Medicaid care is provided to
25    children if either (i) the facility devoted exclusively to
26    caring for children is separately licensed as a hospital by

 

 

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1    a municipality prior to September 30, 1998 or (ii) the
2    hospital has been designated by the State as a Level III
3    perinatal care facility, has a Medicaid Inpatient
4    Utilization rate greater than 55% for the rate year 2003
5    disproportionate share determination, and has more than
6    10,000 qualified children days as defined by the Department
7    in rulemaking.
8    (c) Inpatient adjustment payments. The adjustment payments
9required by paragraph (b) shall be calculated based upon the
10hospital's Medicaid inpatient utilization rate as follows:
11        (1) hospitals with a Medicaid inpatient utilization
12    rate below the mean shall receive a per day adjustment
13    payment equal to $25;
14        (2) hospitals with a Medicaid inpatient utilization
15    rate that is equal to or greater than the mean Medicaid
16    inpatient utilization rate but less than one standard
17    deviation above the mean Medicaid inpatient utilization
18    rate shall receive a per day adjustment payment equal to
19    the sum of $25 plus $1 for each one percent that the
20    hospital's Medicaid inpatient utilization rate exceeds the
21    mean Medicaid inpatient utilization rate;
22        (3) hospitals with a Medicaid inpatient utilization
23    rate that is equal to or greater than one standard
24    deviation above the mean Medicaid inpatient utilization
25    rate but less than 1.5 standard deviations above the mean
26    Medicaid inpatient utilization rate shall receive a per day

 

 

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1    adjustment payment equal to the sum of $40 plus $7 for each
2    one percent that the hospital's Medicaid inpatient
3    utilization rate exceeds one standard deviation above the
4    mean Medicaid inpatient utilization rate; and
5        (4) hospitals with a Medicaid inpatient utilization
6    rate that is equal to or greater than 1.5 standard
7    deviations above the mean Medicaid inpatient utilization
8    rate shall receive a per day adjustment payment equal to
9    the sum of $90 plus $2 for each one percent that the
10    hospital's Medicaid inpatient utilization rate exceeds 1.5
11    standard deviations above the mean Medicaid inpatient
12    utilization rate.
13    (d) Supplemental adjustment payments. In addition to the
14adjustment payments described in paragraph (c), hospitals as
15defined in clauses (1) through (5) of paragraph (b), excluding
16county hospitals (as defined in subsection (c) of Section 15-1
17of this Code) and a hospital organized under the University of
18Illinois Hospital Act, shall be paid supplemental inpatient
19adjustment payments of $60 per day. For purposes of Title XIX
20of the federal Social Security Act, these supplemental
21adjustment payments shall not be classified as adjustment
22payments to disproportionate share hospitals.
23    (e) The inpatient adjustment payments described in
24paragraphs (c) and (d) shall be increased on October 1, 1993
25and annually thereafter by a percentage equal to the lesser of
26(i) the increase in the DRI hospital cost index for the most

 

 

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1recent 12 month period for which data are available, or (ii)
2the percentage increase in the statewide average hospital
3payment rate over the previous year's statewide average
4hospital payment rate. The sum of the inpatient adjustment
5payments under paragraphs (c) and (d) to a hospital, other than
6a county hospital (as defined in subsection (c) of Section 15-1
7of this Code) or a hospital organized under the University of
8Illinois Hospital Act, however, shall not exceed $275 per day;
9that limit shall be increased on October 1, 1993 and annually
10thereafter by a percentage equal to the lesser of (i) the
11increase in the DRI hospital cost index for the most recent
1212-month period for which data are available or (ii) the
13percentage increase in the statewide average hospital payment
14rate over the previous year's statewide average hospital
15payment rate.
16    (f) Children's hospital inpatient adjustment payments. For
17children's hospitals, as defined in clause (5) of paragraph
18(b), the adjustment payments required pursuant to paragraphs
19(c) and (d) shall be multiplied by 2.0.
20    (g) County hospital inpatient adjustment payments. For
21county hospitals, as defined in subsection (c) of Section 15-1
22of this Code, there shall be an adjustment payment as
23determined by rules issued by the Illinois Department.
24    (h) For the purposes of this Section the following terms
25shall be defined as follows:
26        (1) "Medicaid inpatient utilization rate" means a

 

 

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1    fraction, the numerator of which is the number of a
2    hospital's inpatient days provided in a given 12-month
3    period to patients who, for such days, were eligible for
4    Medicaid under Title XIX of the federal Social Security
5    Act, and the denominator of which is the total number of
6    the hospital's inpatient days in that same period.
7        (2) "Mean Medicaid inpatient utilization rate" means
8    the total number of Medicaid inpatient days provided by all
9    Illinois Medicaid-participating hospitals divided by the
10    total number of inpatient days provided by those same
11    hospitals.
12        (3) "Medicaid obstetrical inpatient utilization rate"
13    means the ratio of Medicaid obstetrical inpatient days to
14    total Medicaid inpatient days for all Illinois hospitals
15    receiving Medicaid payments from the Illinois Department.
16    (i) Inpatient adjustment payment limit. In order to meet
17the limits of Public Law 102-234 and Public Law 103-66, the
18Illinois Department shall by rule adjust disproportionate
19share adjustment payments.
20    (j) University of Illinois Hospital inpatient adjustment
21payments. For hospitals organized under the University of
22Illinois Hospital Act, there shall be an adjustment payment as
23determined by rules adopted by the Illinois Department.
24    (k) The Illinois Department may by rule establish criteria
25for and develop methodologies for adjustment payments to
26hospitals participating under this Article.

 

 

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1    (l) On and after July 1, 2012, the Department shall reduce
2any rate of reimbursement for services or other payments or
3alter any methodologies authorized by this Code to reduce any
4rate of reimbursement for services or other payments in
5accordance with Section 5-5e.
6(Source: P.A. 96-31, eff. 6-30-09.)
 
7    (305 ILCS 5/5-5.05)
8    Sec. 5-5.05. Hospitals; psychiatric services.
9    (a) On and after July 1, 2008, the inpatient, per diem rate
10to be paid to a hospital for inpatient psychiatric services
11shall be $363.77.
12    (b) For purposes of this Section, "hospital" means the
13following:
14        (1) Advocate Christ Hospital, Oak Lawn, Illinois.
15        (2) Barnes-Jewish Hospital, St. Louis, Missouri.
16        (3) BroMenn Healthcare, Bloomington, Illinois.
17        (4) Jackson Park Hospital, Chicago, Illinois.
18        (5) Katherine Shaw Bethea Hospital, Dixon, Illinois.
19        (6) Lawrence County Memorial Hospital, Lawrenceville,
20    Illinois.
21        (7) Advocate Lutheran General Hospital, Park Ridge,
22    Illinois.
23        (8) Mercy Hospital and Medical Center, Chicago,
24    Illinois.
25        (9) Methodist Medical Center of Illinois, Peoria,

 

 

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1    Illinois.
2        (10) Provena United Samaritans Medical Center,
3    Danville, Illinois.
4        (11) Rockford Memorial Hospital, Rockford, Illinois.
5        (12) Sarah Bush Lincoln Health Center, Mattoon,
6    Illinois.
7        (13) Provena Covenant Medical Center, Urbana,
8    Illinois.
9        (14) Rush-Presbyterian-St. Luke's Medical Center,
10    Chicago, Illinois.
11        (15) Mt. Sinai Hospital, Chicago, Illinois.
12        (16) Gateway Regional Medical Center, Granite City,
13    Illinois.
14        (17) St. Mary of Nazareth Hospital, Chicago, Illinois.
15        (18) Provena St. Mary's Hospital, Kankakee, Illinois.
16        (19) St. Mary's Hospital, Decatur, Illinois.
17        (20) Memorial Hospital, Belleville, Illinois.
18        (21) Swedish Covenant Hospital, Chicago, Illinois.
19        (22) Trinity Medical Center, Rock Island, Illinois.
20        (23) St. Elizabeth Hospital, Chicago, Illinois.
21        (24) Richland Memorial Hospital, Olney, Illinois.
22        (25) St. Elizabeth's Hospital, Belleville, Illinois.
23        (26) Samaritan Health System, Clinton, Iowa.
24        (27) St. John's Hospital, Springfield, Illinois.
25        (28) St. Mary's Hospital, Centralia, Illinois.
26        (29) Loretto Hospital, Chicago, Illinois.

 

 

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1        (30) Kenneth Hall Regional Hospital, East St. Louis,
2    Illinois.
3        (31) Hinsdale Hospital, Hinsdale, Illinois.
4        (32) Pekin Hospital, Pekin, Illinois.
5        (33) University of Chicago Medical Center, Chicago,
6    Illinois.
7        (34) St. Anthony's Health Center, Alton, Illinois.
8        (35) OSF St. Francis Medical Center, Peoria, Illinois.
9        (36) Memorial Medical Center, Springfield, Illinois.
10        (37) A hospital with a distinct part unit for
11    psychiatric services that begins operating on or after July
12    1, 2008.
13    For purposes of this Section, "inpatient psychiatric
14services" means those services provided to patients who are in
15need of short-term acute inpatient hospitalization for active
16treatment of an emotional or mental disorder.
17    (c) No rules shall be promulgated to implement this
18Section. For purposes of this Section, "rules" is given the
19meaning contained in Section 1-70 of the Illinois
20Administrative Procedure Act.
21    (d) This Section shall not be in effect during any period
22of time that the State has in place a fully operational
23hospital assessment plan that has been approved by the Centers
24for Medicare and Medicaid Services of the U.S. Department of
25Health and Human Services.
26    (e) On and after July 1, 2012, the Department shall reduce

 

 

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1any rate of reimbursement for services or other payments or
2alter any methodologies authorized by this Code to reduce any
3rate of reimbursement for services or other payments in
4accordance with Section 5-5e.
5(Source: P.A. 95-1013, eff. 12-15-08.)
 
6    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
7    Sec. 5-5.2. Payment.
8    (a) All nursing facilities that are grouped pursuant to
9Section 5-5.1 of this Act shall receive the same rate of
10payment for similar services.
11    (b) It shall be a matter of State policy that the Illinois
12Department shall utilize a uniform billing cycle throughout the
13State for the long-term care providers.
14    (c) Notwithstanding any other provisions of this Code,
15beginning July 1, 2012 the methodologies for reimbursement of
16nursing facility services as provided under this Article shall
17no longer be applicable for bills payable for nursing services
18rendered on or after a new reimbursement system based on the
19Resource Utilization Groups (RUGs) has been fully
20operationalized, which shall take effect for services provided
21on or after January 1, 2014. State fiscal years 2012 and
22thereafter. The Department of Healthcare and Family Services
23shall, effective July 1, 2012, implement an evidence-based
24payment methodology for the reimbursement of nursing facility
25services. The methodology shall continue to take into

 

 

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1consideration the needs of individual residents, as assessed
2and reported by the most current version of the nursing
3facility Resident Assessment Instrument, adopted and in use by
4the federal government.
5    (d) A new nursing services reimbursement methodology
6utilizing RUGs IV 48 grouper model shall be established and may
7include an Illinois-specific default group, as needed. The new
8RUGs-based nursing services reimbursement methodology shall be
9resident-driven, facility-specific, and cost-based. Costs
10shall be annually rebased and case mix index quarterly updated.
11The methodology shall include regional wage adjustors based on
12the Health Service Areas (HSA) groupings in effect on April 30,
132012. The Department shall assign a case mix index to each
14resident class based on the Centers for Medicare and Medicaid
15Services staff time measurement study utilizing an index
16maximization approach.
17    (e) Notwithstanding any other provision of this Code, the
18Department shall by rule develop a reimbursement methodology
19reflective of the intensity of care and services requirements
20of low need residents in the lowest RUG IV groupers and
21corresponding regulations.
22    (f) Notwithstanding any other provision of this Code, on
23and after July 1, 2012, reimbursement rates associated with the
24nursing or support components of the current nursing facility
25rate methodology shall not increase beyond the level effective
26May 1, 2011 until a new reimbursement system based on the RUGs

 

 

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1IV 48 grouper model has been fully operationalized.
2    (g) Notwithstanding any other provision of this Code, on
3and after July 1, 2012, for facilities not designated by the
4Department of Healthcare and Family Services as "Institutions
5for Mental Disease", rates effective May 1, 2011 shall be
6adjusted as follows:
7        (1) Individual nursing rates for residents classified
8    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
9    ending March 31, 2012 shall be reduced by 10%;
10        (2) Individual nursing rates for residents classified
11    in all other RUG IV groups shall be reduced by 1.0%;
12        (3) Facility rates for the capital and support
13    components shall be reduced by 1.7%.
14    (h) Notwithstanding any other provision of this Code, on
15and after July 1, 2012, nursing facilities designated by the
16Department of Healthcare and Family Services as "Institutions
17for Mental Disease" and "Institutions for Mental Disease" that
18are facilities licensed under the Specialized Mental Health
19Rehabilitation Act shall have the nursing,
20socio-developmental, capital, and support components of their
21reimbursement rate effective May 1, 2011 reduced in total by
222.7%.
23(Source: P.A. 96-1530, eff. 2-16-11.)
 
24    (305 ILCS 5/5-5.3)  (from Ch. 23, par. 5-5.3)
25    Sec. 5-5.3. Conditions of Payment - Prospective Rates -

 

 

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1Accounting Principles. This amendatory Act establishes certain
2conditions for the Department of Healthcare and Family Services
3in instituting rates for the care of recipients of medical
4assistance in nursing facilities and ICF/DDs. Such conditions
5shall assure a method under which the payment for nursing
6facility and ICF/DD services provided to recipients under the
7Medical Assistance Program shall be on a reasonable cost
8related basis, which is prospectively determined at least
9annually by the Department of Public Aid (now Healthcare and
10Family Services). The annually established payment rate shall
11take effect on July 1 in 1984 and subsequent years. There shall
12be no rate increase during calendar year 1983 and the first six
13months of calendar year 1984.
14    The determination of the payment shall be made on the basis
15of generally accepted accounting principles that shall take
16into account the actual costs to the facility of providing
17nursing facility and ICF/DD services to recipients under the
18medical assistance program.
19    The resultant total rate for a specified type of service
20shall be an amount which shall have been determined to be
21adequate to reimburse allowable costs of a facility that is
22economically and efficiently operated. The Department shall
23establish an effective date for each facility or group of
24facilities after which rates shall be paid on a reasonable cost
25related basis which shall be no sooner than the effective date
26of this amendatory Act of 1977.

 

 

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1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate of
4reimbursement for services or other payments in accordance with
5Section 5-5e.
6(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
 
7    (305 ILCS 5/5-5.4)  (from Ch. 23, par. 5-5.4)
8    Sec. 5-5.4. Standards of Payment - Department of Healthcare
9and Family Services. The Department of Healthcare and Family
10Services shall develop standards of payment of nursing facility
11and ICF/DD services in facilities providing such services under
12this Article which:
13    (1) Provide for the determination of a facility's payment
14for nursing facility or ICF/DD services on a prospective basis.
15The amount of the payment rate for all nursing facilities
16certified by the Department of Public Health under the ID/DD
17Community Care Act or the Nursing Home Care Act as Intermediate
18Care for the Developmentally Disabled facilities, Long Term
19Care for Under Age 22 facilities, Skilled Nursing facilities,
20or Intermediate Care facilities under the medical assistance
21program shall be prospectively established annually on the
22basis of historical, financial, and statistical data
23reflecting actual costs from prior years, which shall be
24applied to the current rate year and updated for inflation,
25except that the capital cost element for newly constructed

 

 

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1facilities shall be based upon projected budgets. The annually
2established payment rate shall take effect on July 1 in 1984
3and subsequent years. No rate increase and no update for
4inflation shall be provided on or after July 1, 1994 and before
5January 1, 2014 July 1, 2012, unless specifically provided for
6in this Section. The changes made by Public Act 93-841
7extending the duration of the prohibition against a rate
8increase or update for inflation are effective retroactive to
9July 1, 2004.
10    For facilities licensed by the Department of Public Health
11under the Nursing Home Care Act as Intermediate Care for the
12Developmentally Disabled facilities or Long Term Care for Under
13Age 22 facilities, the rates taking effect on July 1, 1998
14shall include an increase of 3%. For facilities licensed by the
15Department of Public Health under the Nursing Home Care Act as
16Skilled Nursing facilities or Intermediate Care facilities,
17the rates taking effect on July 1, 1998 shall include an
18increase of 3% plus $1.10 per resident-day, as defined by the
19Department. For facilities licensed by the Department of Public
20Health under the Nursing Home Care Act as Intermediate Care
21Facilities for the Developmentally Disabled or Long Term Care
22for Under Age 22 facilities, the rates taking effect on January
231, 2006 shall include an increase of 3%. For facilities
24licensed by the Department of Public Health under the Nursing
25Home Care Act as Intermediate Care Facilities for the
26Developmentally Disabled or Long Term Care for Under Age 22

 

 

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1facilities, the rates taking effect on January 1, 2009 shall
2include an increase sufficient to provide a $0.50 per hour wage
3increase for non-executive staff.
4    For facilities licensed by the Department of Public Health
5under the Nursing Home Care Act as Intermediate Care for the
6Developmentally Disabled facilities or Long Term Care for Under
7Age 22 facilities, the rates taking effect on July 1, 1999
8shall include an increase of 1.6% plus $3.00 per resident-day,
9as defined by the Department. For facilities licensed by the
10Department of Public Health under the Nursing Home Care Act as
11Skilled Nursing facilities or Intermediate Care facilities,
12the rates taking effect on July 1, 1999 shall include an
13increase of 1.6% and, for services provided on or after October
141, 1999, shall be increased by $4.00 per resident-day, as
15defined by the Department.
16    For facilities licensed by the Department of Public Health
17under the Nursing Home Care Act as Intermediate Care for the
18Developmentally Disabled facilities or Long Term Care for Under
19Age 22 facilities, the rates taking effect on July 1, 2000
20shall include an increase of 2.5% per resident-day, as defined
21by the Department. For facilities licensed by the Department of
22Public Health under the Nursing Home Care Act as Skilled
23Nursing facilities or Intermediate Care facilities, the rates
24taking effect on July 1, 2000 shall include an increase of 2.5%
25per resident-day, as defined by the Department.
26    For facilities licensed by the Department of Public Health

 

 

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1under the Nursing Home Care Act as skilled nursing facilities
2or intermediate care facilities, a new payment methodology must
3be implemented for the nursing component of the rate effective
4July 1, 2003. The Department of Public Aid (now Healthcare and
5Family Services) shall develop the new payment methodology
6using the Minimum Data Set (MDS) as the instrument to collect
7information concerning nursing home resident condition
8necessary to compute the rate. The Department shall develop the
9new payment methodology to meet the unique needs of Illinois
10nursing home residents while remaining subject to the
11appropriations provided by the General Assembly. A transition
12period from the payment methodology in effect on June 30, 2003
13to the payment methodology in effect on July 1, 2003 shall be
14provided for a period not exceeding 3 years and 184 days after
15implementation of the new payment methodology as follows:
16        (A) For a facility that would receive a lower nursing
17    component rate per patient day under the new system than
18    the facility received effective on the date immediately
19    preceding the date that the Department implements the new
20    payment methodology, the nursing component rate per
21    patient day for the facility shall be held at the level in
22    effect on the date immediately preceding the date that the
23    Department implements the new payment methodology until a
24    higher nursing component rate of reimbursement is achieved
25    by that facility.
26        (B) For a facility that would receive a higher nursing

 

 

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1    component rate per patient day under the payment
2    methodology in effect on July 1, 2003 than the facility
3    received effective on the date immediately preceding the
4    date that the Department implements the new payment
5    methodology, the nursing component rate per patient day for
6    the facility shall be adjusted.
7        (C) Notwithstanding paragraphs (A) and (B), the
8    nursing component rate per patient day for the facility
9    shall be adjusted subject to appropriations provided by the
10    General Assembly.
11    For facilities licensed by the Department of Public Health
12under the Nursing Home Care Act as Intermediate Care for the
13Developmentally Disabled facilities or Long Term Care for Under
14Age 22 facilities, the rates taking effect on March 1, 2001
15shall include a statewide increase of 7.85%, as defined by the
16Department.
17    Notwithstanding any other provision of this Section, for
18facilities licensed by the Department of Public Health under
19the Nursing Home Care Act as skilled nursing facilities or
20intermediate care facilities, except facilities participating
21in the Department's demonstration program pursuant to the
22provisions of Title 77, Part 300, Subpart T of the Illinois
23Administrative Code, the numerator of the ratio used by the
24Department of Healthcare and Family Services to compute the
25rate payable under this Section using the Minimum Data Set
26(MDS) methodology shall incorporate the following annual

 

 

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1amounts as the additional funds appropriated to the Department
2specifically to pay for rates based on the MDS nursing
3component methodology in excess of the funding in effect on
4December 31, 2006:
5        (i) For rates taking effect January 1, 2007,
6    $60,000,000.
7        (ii) For rates taking effect January 1, 2008,
8    $110,000,000.
9        (iii) For rates taking effect January 1, 2009,
10    $194,000,000.
11        (iv) For rates taking effect April 1, 2011, or the
12    first day of the month that begins at least 45 days after
13    the effective date of this amendatory Act of the 96th
14    General Assembly, $416,500,000 or an amount as may be
15    necessary to complete the transition to the MDS methodology
16    for the nursing component of the rate. Increased payments
17    under this item (iv) are not due and payable, however,
18    until (i) the methodologies described in this paragraph are
19    approved by the federal government in an appropriate State
20    Plan amendment and (ii) the assessment imposed by Section
21    5B-2 of this Code is determined to be a permissible tax
22    under Title XIX of the Social Security Act.
23    Notwithstanding any other provision of this Section, for
24facilities licensed by the Department of Public Health under
25the Nursing Home Care Act as skilled nursing facilities or
26intermediate care facilities, the support component of the

 

 

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1rates taking effect on January 1, 2008 shall be computed using
2the most recent cost reports on file with the Department of
3Healthcare and Family Services no later than April 1, 2005,
4updated for inflation to January 1, 2006.
5    For facilities licensed by the Department of Public Health
6under the Nursing Home Care Act as Intermediate Care for the
7Developmentally Disabled facilities or Long Term Care for Under
8Age 22 facilities, the rates taking effect on April 1, 2002
9shall include a statewide increase of 2.0%, as defined by the
10Department. This increase terminates on July 1, 2002; beginning
11July 1, 2002 these rates are reduced to the level of the rates
12in effect on March 31, 2002, as defined by the Department.
13    For facilities licensed by the Department of Public Health
14under the Nursing Home Care Act as skilled nursing facilities
15or intermediate care facilities, the rates taking effect on
16July 1, 2001 shall be computed using the most recent cost
17reports on file with the Department of Public Aid no later than
18April 1, 2000, updated for inflation to January 1, 2001. For
19rates effective July 1, 2001 only, rates shall be the greater
20of the rate computed for July 1, 2001 or the rate effective on
21June 30, 2001.
22    Notwithstanding any other provision of this Section, for
23facilities licensed by the Department of Public Health under
24the Nursing Home Care Act as skilled nursing facilities or
25intermediate care facilities, the Illinois Department shall
26determine by rule the rates taking effect on July 1, 2002,

 

 

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1which shall be 5.9% less than the rates in effect on June 30,
22002.
3    Notwithstanding any other provision of this Section, for
4facilities licensed by the Department of Public Health under
5the Nursing Home Care Act as skilled nursing facilities or
6intermediate care facilities, if the payment methodologies
7required under Section 5A-12 and the waiver granted under 42
8CFR 433.68 are approved by the United States Centers for
9Medicare and Medicaid Services, the rates taking effect on July
101, 2004 shall be 3.0% greater than the rates in effect on June
1130, 2004. These rates shall take effect only upon approval and
12implementation of the payment methodologies required under
13Section 5A-12.
14    Notwithstanding any other provisions of this Section, for
15facilities licensed by the Department of Public Health under
16the Nursing Home Care Act as skilled nursing facilities or
17intermediate care facilities, the rates taking effect on
18January 1, 2005 shall be 3% more than the rates in effect on
19December 31, 2004.
20    Notwithstanding any other provision of this Section, for
21facilities licensed by the Department of Public Health under
22the Nursing Home Care Act as skilled nursing facilities or
23intermediate care facilities, effective January 1, 2009, the
24per diem support component of the rates effective on January 1,
252008, computed using the most recent cost reports on file with
26the Department of Healthcare and Family Services no later than

 

 

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1April 1, 2005, updated for inflation to January 1, 2006, shall
2be increased to the amount that would have been derived using
3standard Department of Healthcare and Family Services methods,
4procedures, and inflators.
5    Notwithstanding any other provisions of this Section, for
6facilities licensed by the Department of Public Health under
7the Nursing Home Care Act as intermediate care facilities that
8are federally defined as Institutions for Mental Disease, or
9facilities licensed by the Department of Public Health under
10the Specialized Mental Health Rehabilitation Facilities Act, a
11socio-development component rate equal to 6.6% of the
12facility's nursing component rate as of January 1, 2006 shall
13be established and paid effective July 1, 2006. The
14socio-development component of the rate shall be increased by a
15factor of 2.53 on the first day of the month that begins at
16least 45 days after January 11, 2008 (the effective date of
17Public Act 95-707). As of August 1, 2008, the socio-development
18component rate shall be equal to 6.6% of the facility's nursing
19component rate as of January 1, 2006, multiplied by a factor of
203.53. For services provided on or after April 1, 2011, or the
21first day of the month that begins at least 45 days after the
22effective date of this amendatory Act of the 96th General
23Assembly, whichever is later, the Illinois Department may by
24rule adjust these socio-development component rates, and may
25use different adjustment methodologies for those facilities
26participating, and those not participating, in the Illinois

 

 

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1Department's demonstration program pursuant to the provisions
2of Title 77, Part 300, Subpart T of the Illinois Administrative
3Code, but in no case may such rates be diminished below those
4in effect on August 1, 2008.
5    For facilities licensed by the Department of Public Health
6under the Nursing Home Care Act as Intermediate Care for the
7Developmentally Disabled facilities or as long-term care
8facilities for residents under 22 years of age, the rates
9taking effect on July 1, 2003 shall include a statewide
10increase of 4%, as defined by the Department.
11    For facilities licensed by the Department of Public Health
12under the Nursing Home Care Act as Intermediate Care for the
13Developmentally Disabled facilities or Long Term Care for Under
14Age 22 facilities, the rates taking effect on the first day of
15the month that begins at least 45 days after the effective date
16of this amendatory Act of the 95th General Assembly shall
17include a statewide increase of 2.5%, as defined by the
18Department.
19    Notwithstanding any other provision of this Section, for
20facilities licensed by the Department of Public Health under
21the Nursing Home Care Act as skilled nursing facilities or
22intermediate care facilities, effective January 1, 2005,
23facility rates shall be increased by the difference between (i)
24a facility's per diem property, liability, and malpractice
25insurance costs as reported in the cost report filed with the
26Department of Public Aid and used to establish rates effective

 

 

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1July 1, 2001 and (ii) those same costs as reported in the
2facility's 2002 cost report. These costs shall be passed
3through to the facility without caps or limitations, except for
4adjustments required under normal auditing procedures.
5    Rates established effective each July 1 shall govern
6payment for services rendered throughout that fiscal year,
7except that rates established on July 1, 1996 shall be
8increased by 6.8% for services provided on or after January 1,
91997. Such rates will be based upon the rates calculated for
10the year beginning July 1, 1990, and for subsequent years
11thereafter until June 30, 2001 shall be based on the facility
12cost reports for the facility fiscal year ending at any point
13in time during the previous calendar year, updated to the
14midpoint of the rate year. The cost report shall be on file
15with the Department no later than April 1 of the current rate
16year. Should the cost report not be on file by April 1, the
17Department shall base the rate on the latest cost report filed
18by each skilled care facility and intermediate care facility,
19updated to the midpoint of the current rate year. In
20determining rates for services rendered on and after July 1,
211985, fixed time shall not be computed at less than zero. The
22Department shall not make any alterations of regulations which
23would reduce any component of the Medicaid rate to a level
24below what that component would have been utilizing in the rate
25effective on July 1, 1984.
26    (2) Shall take into account the actual costs incurred by

 

 

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1facilities in providing services for recipients of skilled
2nursing and intermediate care services under the medical
3assistance program.
4    (3) Shall take into account the medical and psycho-social
5characteristics and needs of the patients.
6    (4) Shall take into account the actual costs incurred by
7facilities in meeting licensing and certification standards
8imposed and prescribed by the State of Illinois, any of its
9political subdivisions or municipalities and by the U.S.
10Department of Health and Human Services pursuant to Title XIX
11of the Social Security Act.
12    The Department of Healthcare and Family Services shall
13develop precise standards for payments to reimburse nursing
14facilities for any utilization of appropriate rehabilitative
15personnel for the provision of rehabilitative services which is
16authorized by federal regulations, including reimbursement for
17services provided by qualified therapists or qualified
18assistants, and which is in accordance with accepted
19professional practices. Reimbursement also may be made for
20utilization of other supportive personnel under appropriate
21supervision.
22    The Department shall develop enhanced payments to offset
23the additional costs incurred by a facility serving exceptional
24need residents and shall allocate at least $8,000,000 of the
25funds collected from the assessment established by Section 5B-2
26of this Code for such payments. For the purpose of this

 

 

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1Section, "exceptional needs" means, but need not be limited to,
2ventilator care, tracheotomy care, bariatric care, complex
3wound care, and traumatic brain injury care. The enhanced
4payments for exceptional need residents under this paragraph
5are not due and payable, however, until (i) the methodologies
6described in this paragraph are approved by the federal
7government in an appropriate State Plan amendment and (ii) the
8assessment imposed by Section 5B-2 of this Code is determined
9to be a permissible tax under Title XIX of the Social Security
10Act.
11    (5) Beginning January July 1, 2014 2012 the methodologies
12for reimbursement of nursing facility services as provided
13under this Section 5-5.4 shall no longer be applicable for
14services provided on or after January 1, 2014 bills payable for
15State fiscal years 2012 and thereafter.
16    (6) No payment increase under this Section for the MDS
17methodology, exceptional care residents, or the
18socio-development component rate established by Public Act
1996-1530 of the 96th General Assembly and funded by the
20assessment imposed under Section 5B-2 of this Code shall be due
21and payable until after the Department notifies the long-term
22care providers, in writing, that the payment methodologies to
23long-term care providers required under this Section have been
24approved by the Centers for Medicare and Medicaid Services of
25the U.S. Department of Health and Human Services and the
26waivers under 42 CFR 433.68 for the assessment imposed by this

 

 

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1Section, if necessary, have been granted by the Centers for
2Medicare and Medicaid Services of the U.S. Department of Health
3and Human Services. Upon notification to the Department of
4approval of the payment methodologies required under this
5Section and the waivers granted under 42 CFR 433.68, all
6increased payments otherwise due under this Section prior to
7the date of notification shall be due and payable within 90
8days of the date federal approval is received.
9    On and after July 1, 2012, the Department shall reduce any
10rate of reimbursement for services or other payments or alter
11any methodologies authorized by this Code to reduce any rate of
12reimbursement for services or other payments in accordance with
13Section 5-5e.
14(Source: P.A. 96-45, eff. 7-15-09; 96-339, eff. 7-1-10; 96-959,
15eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1530, eff. 2-16-11;
1697-10, eff. 6-14-11; 97-38, eff. 6-28-11; 97-227, eff. 1-1-12;
1797-584, eff. 8-26-11; revised 10-4-11.)
 
18    (305 ILCS 5/5-5.4e)
19    Sec. 5-5.4e. Nursing facilities; ventilator rates. On and
20after October 1, 2009, the Department of Healthcare and Family
21Services shall adopt rules to provide medical assistance
22reimbursement under this Article for the care of persons on
23ventilators in skilled nursing facilities licensed under the
24Nursing Home Care Act and certified to participate under the
25medical assistance program. Accordingly, necessary amendments

 

 

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1to the rules implementing the Minimum Data Set (MDS) payment
2methodology shall also be made to provide a separate per diem
3ventilator rate based on days of service. The Department may
4adopt rules necessary to implement this amendatory Act of the
596th General Assembly through the use of emergency rulemaking
6in accordance with Section 5-45 of the Illinois Administrative
7Procedure Act, except that the 24-month limitation on the
8adoption of emergency rules under Section 5-45 and the
9provisions of Sections 5-115 and 5-125 of that Act do not apply
10to rules adopted under this Section. For purposes of that Act,
11the General Assembly finds that the adoption of rules to
12implement this amendatory Act of the 96th General Assembly is
13deemed an emergency and necessary for the public interest,
14safety, and welfare.
15    On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate of
18reimbursement for services or other payments in accordance with
19Section 5-5e.
20(Source: P.A. 96-743, eff. 8-25-09.)
 
21    (305 ILCS 5/5-5.5)  (from Ch. 23, par. 5-5.5)
22    Sec. 5-5.5. Elements of Payment Rate.
23    (a) The Department of Healthcare and Family Services shall
24develop a prospective method for determining payment rates for
25nursing facility and ICF/DD services in nursing facilities

 

 

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1composed of the following cost elements:
2        (1) Standard Services, with the cost of this component
3    being determined by taking into account the actual costs to
4    the facilities of these services subject to cost ceilings
5    to be defined in the Department's rules.
6        (2) Resident Services, with the cost of this component
7    being determined by taking into account the actual costs,
8    needs and utilization of these services, as derived from an
9    assessment of the resident needs in the nursing facilities.
10        (3) Ancillary Services, with the payment rate being
11    developed for each individual type of service. Payment
12    shall be made only when authorized under procedures
13    developed by the Department of Healthcare and Family
14    Services.
15        (4) Nurse's Aide Training, with the cost of this
16    component being determined by taking into account the
17    actual cost to the facilities of such training.
18        (5) Real Estate Taxes, with the cost of this component
19    being determined by taking into account the figures
20    contained in the most currently available cost reports
21    (with no imposition of maximums) updated to the midpoint of
22    the current rate year for long term care services rendered
23    between July 1, 1984 and June 30, 1985, and with the cost
24    of this component being determined by taking into account
25    the actual 1983 taxes for which the nursing homes were
26    assessed (with no imposition of maximums) updated to the

 

 

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1    midpoint of the current rate year for long term care
2    services rendered between July 1, 1985 and June 30, 1986.
3    (b) In developing a prospective method for determining
4payment rates for nursing facility and ICF/DD services in
5nursing facilities and ICF/DDs, the Department of Healthcare
6and Family Services shall consider the following cost elements:
7        (1) Reasonable capital cost determined by utilizing
8    incurred interest rate and the current value of the
9    investment, including land, utilizing composite rates, or
10    by utilizing such other reasonable cost related methods
11    determined by the Department. However, beginning with the
12    rate reimbursement period effective July 1, 1987, the
13    Department shall be prohibited from establishing,
14    including, and implementing any depreciation factor in
15    calculating the capital cost element.
16        (2) Profit, with the actual amount being produced and
17    accruing to the providers in the form of a return on their
18    total investment, on the basis of their ability to
19    economically and efficiently deliver a type of service. The
20    method of payment may assure the opportunity for a profit,
21    but shall not guarantee or establish a specific amount as a
22    cost.
23    (c) The Illinois Department may implement the amendatory
24changes to this Section made by this amendatory Act of 1991
25through the use of emergency rules in accordance with the
26provisions of Section 5.02 of the Illinois Administrative

 

 

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1Procedure Act. For purposes of the Illinois Administrative
2Procedure Act, the adoption of rules to implement the
3amendatory changes to this Section made by this amendatory Act
4of 1991 shall be deemed an emergency and necessary for the
5public interest, safety and welfare.
6    (d) No later than January 1, 2001, the Department of Public
7Aid shall file with the Joint Committee on Administrative
8Rules, pursuant to the Illinois Administrative Procedure Act, a
9proposed rule, or a proposed amendment to an existing rule,
10regarding payment for appropriate services, including
11assessment, care planning, discharge planning, and treatment
12provided by nursing facilities to residents who have a serious
13mental illness.
14    (e) On and after July 1, 2012, the Department shall reduce
15any rate of reimbursement for services or other payments or
16alter any methodologies authorized by this Code to reduce any
17rate of reimbursement for services or other payments in
18accordance with Section 5-5e.
19(Source: P.A. 95-331, eff. 8-21-07; 96-1123, eff. 1-1-11;
2096-1530, eff. 2-16-11.)
 
21    (305 ILCS 5/5-5.8b)  (from Ch. 23, par. 5-5.8b)
22    Sec. 5-5.8b. Payment to Campus Facilities. There is hereby
23established a separate payment category for campus facilities.
24A "campus facility" is defined as an entity which consists of a
25long term care facility (or group of facilities if the

 

 

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1facilities are on the same contiguous parcel of real estate)
2which meets all of the following criteria as of May 1, 1987:
3the entity provides care for both children and adults;
4residents of the entity reside in three or more separate
5buildings with congregate and small group living arrangements
6on a single campus; the entity provides three or more separate
7licensed levels of care; the entity (or a part of the entity)
8is enrolled with the Department of Healthcare and Family
9Services as a provider of long term care services and receives
10payments from that Department; the entity (or a part of the
11entity) receives funding from the Department of Human Services;
12and the entity (or a part of the entity) holds a current
13license as a child care institution issued by the Department of
14Children and Family Services.
15    The Department of Healthcare and Family Services, the
16Department of Human Services, and the Department of Children
17and Family Services shall develop jointly a rate methodology or
18methodologies for campus facilities. Such methodology or
19methodologies may establish a single rate to be paid by all the
20agencies, or a separate rate to be paid by each agency, or
21separate components to be paid to different parts of the campus
22facility. All campus facilities shall receive the same rate of
23payment for similar services. Any methodology developed
24pursuant to this section shall take into account the actual
25costs to the facility of providing services to residents, and
26shall be adequate to reimburse the allowable costs of a campus

 

 

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1facility which is economically and efficiently operated. Any
2methodology shall be established on the basis of historical,
3financial, and statistical data submitted by campus
4facilities, and shall take into account the actual costs
5incurred by campus facilities in providing services, and in
6meeting licensing and certification standards imposed and
7prescribed by the State of Illinois, any of its political
8subdivisions or municipalities and by the United States
9Department of Health and Human Services. Rates may be
10established on a prospective or retrospective basis. Any
11methodology shall provide reimbursement for appropriate
12payment elements, including the following: standard services,
13patient services, real estate taxes, and capital costs.
14    On and after July 1, 2012, the Department shall reduce any
15rate of reimbursement for services or other payments or alter
16any methodologies authorized by this Code to reduce any rate of
17reimbursement for services or other payments in accordance with
18Section 5-5e.
19(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
 
20    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
21    Sec. 5-5.12. Pharmacy payments.
22    (a) Every request submitted by a pharmacy for reimbursement
23under this Article for prescription drugs provided to a
24recipient of aid under this Article shall include the name of
25the prescriber or an acceptable identification number as

 

 

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1established by the Department.
2    (b) Pharmacies providing prescription drugs under this
3Article shall be reimbursed at a rate which shall include a
4professional dispensing fee as determined by the Illinois
5Department, plus the current acquisition cost of the
6prescription drug dispensed. The Illinois Department shall
7update its information on the acquisition costs of all
8prescription drugs no less frequently than every 30 days.
9However, the Illinois Department may set the rate of
10reimbursement for the acquisition cost, by rule, at a
11percentage of the current average wholesale acquisition cost.
12    (c) (Blank).
13    (d) The Department shall not impose requirements for prior
14approval based on a preferred drug list for anti-retroviral,
15anti-hemophilic factor concentrates, or any atypical
16antipsychotics, conventional antipsychotics, or
17anticonvulsants used for the treatment of serious mental
18illnesses until 30 days after it has conducted a study of the
19impact of such requirements on patient care and submitted a
20report to the Speaker of the House of Representatives and the
21President of the Senate. The Department shall review
22utilization of narcotic medications in the medical assistance
23program and impose utilization controls that protect against
24abuse.
25    (e) When making determinations as to which drugs shall be
26on a prior approval list, the Department shall include as part

 

 

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1of the analysis for this determination, the degree to which a
2drug may affect individuals in different ways based on factors
3including the gender of the person taking the medication.
4    (f) The Department shall cooperate with the Department of
5Public Health and the Department of Human Services Division of
6Mental Health in identifying psychotropic medications that,
7when given in a particular form, manner, duration, or frequency
8(including "as needed") in a dosage, or in conjunction with
9other psychotropic medications to a nursing home resident or to
10a resident of a facility licensed under the ID/DD MR/DD
11Community Care Act, may constitute a chemical restraint or an
12"unnecessary drug" as defined by the Nursing Home Care Act or
13Titles XVIII and XIX of the Social Security Act and the
14implementing rules and regulations. The Department shall
15require prior approval for any such medication prescribed for a
16nursing home resident or to a resident of a facility licensed
17under the ID/DD MR/DD Community Care Act, that appears to be a
18chemical restraint or an unnecessary drug. The Department shall
19consult with the Department of Human Services Division of
20Mental Health in developing a protocol and criteria for
21deciding whether to grant such prior approval.
22    (g) The Department may by rule provide for reimbursement of
23the dispensing of a 90-day supply of a generic or brand name,
24non-narcotic maintenance medication in circumstances where it
25is cost effective.
26    (g-5) On and after July 1, 2012, the Department may require

 

 

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1the dispensing of drugs to nursing home residents be in a 7-day
2supply or other amount less than a 31-day supply. The
3Department shall pay only one dispensing fee per 31-day supply.
4    (h) Effective July 1, 2011, the Department shall
5discontinue coverage of select over-the-counter drugs,
6including analgesics and cough and cold and allergy
7medications.
8    (h-5) On and after July 1, 2012, the Department shall
9impose utilization controls, including, but not limited to,
10prior approval on specialty drugs, oncolytic drugs, drugs for
11the treatment of HIV or AIDS, immunosuppressant drugs, and
12biological products in order to maximize savings on these
13drugs. The Department may adjust payment methodologies for
14non-pharmacy billed drugs in order to incentivize the selection
15of lower-cost drugs. For drugs for the treatment of AIDS, the
16Department shall take into consideration the potential for
17non-adherence by certain populations, and shall develop
18protocols with organizations or providers primarily serving
19those with HIV/AIDS, as long as such measures intend to
20maintain cost neutrality with other utilization management
21controls such as prior approval. For hemophilia, the Department
22shall develop a program of utilization review and control which
23may include, in the discretion of the Department, prior
24approvals. The Department may impose special standards on
25providers that dispense blood factors which shall include, in
26the discretion of the Department, staff training and education;

 

 

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1patient outreach and education; case management; in-home
2patient assessments; assay management; maintenance of stock;
3emergency dispensing timeframes; data collection and
4reporting; dispensing of supplies related to blood factor
5infusions; cold chain management and packaging practices; care
6coordination; product recalls; and emergency clinical
7consultation. The Department may require patients to receive a
8comprehensive examination annually at an appropriate provider
9in order to be eligible to continue to receive blood factor.
10    (i) On and after July 1, 2012, the Department shall reduce
11any rate of reimbursement for services or other payments or
12alter any methodologies authorized by this Code to reduce any
13rate of reimbursement for services or other payments in
14accordance with Section 5-5e.
15    (i) (Blank). The Department shall seek any necessary waiver
16from the federal government in order to establish a program
17limiting the pharmacies eligible to dispense specialty drugs
18and shall issue a Request for Proposals in order to maximize
19savings on these drugs. The Department shall by rule establish
20the drugs required to be dispensed in this program.
21    (j) On and after July 1, 2012, the Department shall impose
22limitations on prescription drugs such that the Department
23shall not provide reimbursement for more than 4 prescriptions,
24including 3 brand name prescriptions, for distinct drugs in a
2530-day period, unless prior approval is received for all
26prescriptions in excess of the 4-prescription limit. Drugs in

 

 

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1the following therapeutic classes shall not be subject to prior
2approval as a result of the 4-prescription limit:
3immunosuppressant drugs, oncolytic drugs, and anti-retroviral
4drugs.
5    (k) No medication therapy management program implemented
6by the Department shall be contrary to the provisions of the
7Pharmacy Practice Act.
8    (l) Any provider enrolled with the Department that bills
9the Department for outpatient drugs and is eligible to enroll
10in the federal Drug Pricing Program under Section 340B of the
11federal Public Health Services Act shall enroll in that
12program. No entity participating in the federal Drug Pricing
13Program under Section 340B of the federal Public Health
14Services Act may exclude Medicaid from their participation in
15that program, although the Department may exclude entities
16defined in Section 1905(l)(2)(B) of the Social Security Act
17from this requirement.
18(Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10;
1996-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff.
206-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; revised
2110-4-11.)
 
22    (305 ILCS 5/5-5.17)  (from Ch. 23, par. 5-5.17)
23    Sec. 5-5.17. Separate reimbursement rate. The Illinois
24Department may by rule establish a separate reimbursement rate
25to be paid to long term care facilities for adult developmental

 

 

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1training services as defined in Section 15.2 of the Mental
2Health and Developmental Disabilities Administrative Act which
3are provided to intellectually disabled residents of such
4facilities who receive aid under this Article. Any such
5reimbursement shall be based upon cost reports submitted by the
6providers of such services and shall be paid by the long term
7care facility to the provider within such time as the Illinois
8Department shall prescribe by rule, but in no case less than 3
9business days after receipt of the reimbursement by such
10facility from the Illinois Department. The Illinois Department
11may impose a penalty upon a facility which does not make
12payment to the provider of adult developmental training
13services within the time so prescribed, up to the amount of
14payment not made to the provider.
15    On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate of
18reimbursement for services or other payments in accordance with
19Section 5-5e.
20(Source: P.A. 97-227, eff. 1-1-12.)
 
21    (305 ILCS 5/5-5.20)
22    Sec. 5-5.20. Clinic payments. For services provided by
23federally qualified health centers as defined in Section 1905
24(l)(2)(B) of the federal Social Security Act, on or after April
251, 1989, and as long as required by federal law, the Illinois

 

 

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1Department shall reimburse those health centers for those
2services according to a prospective cost-reimbursement
3methodology.
4    On and after July 1, 2012, the Department shall reduce any
5rate of reimbursement for services or other payments or alter
6any methodologies authorized by this Code to reduce any rate of
7reimbursement for services or other payments in accordance with
8Section 5-5e.
9(Source: P.A. 89-38, eff. 1-1-96.)
 
10    (305 ILCS 5/5-5.23)
11    Sec. 5-5.23. Children's mental health services.
12    (a) The Department of Healthcare and Family Services, by
13rule, shall require the screening and assessment of a child
14prior to any Medicaid-funded admission to an inpatient hospital
15for psychiatric services to be funded by Medicaid. The
16screening and assessment shall include a determination of the
17appropriateness and availability of out-patient support
18services for necessary treatment. The Department, by rule,
19shall establish methods and standards of payment for the
20screening, assessment, and necessary alternative support
21services.
22    (b) The Department of Healthcare and Family Services, to
23the extent allowable under federal law, shall secure federal
24financial participation for Individual Care Grant expenditures
25made by the Department of Human Services for the Medicaid

 

 

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1optional service authorized under Section 1905(h) of the
2federal Social Security Act, pursuant to the provisions of
3Section 7.1 of the Mental Health and Developmental Disabilities
4Administrative Act.
5    (c) The Department of Healthcare and Family Services shall
6work jointly with the Department of Human Services to implement
7subsections (a) and (b).
8    (d) On and after July 1, 2012, the Department shall reduce
9any rate of reimbursement for services or other payments or
10alter any methodologies authorized by this Code to reduce any
11rate of reimbursement for services or other payments in
12accordance with Section 5-5e.
13(Source: P.A. 95-331, eff. 8-21-07.)
 
14    (305 ILCS 5/5-5.24)
15    Sec. 5-5.24. Prenatal and perinatal care. The Department of
16Healthcare and Family Services may provide reimbursement under
17this Article for all prenatal and perinatal health care
18services that are provided for the purpose of preventing
19low-birthweight infants, reducing the need for neonatal
20intensive care hospital services, and promoting perinatal
21health. These services may include comprehensive risk
22assessments for pregnant women, women with infants, and
23infants, lactation counseling, nutrition counseling,
24childbirth support, psychosocial counseling, treatment and
25prevention of periodontal disease, and other support services

 

 

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1that have been proven to improve birth outcomes. The Department
2shall maximize the use of preventive prenatal and perinatal
3health care services consistent with federal statutes, rules,
4and regulations. The Department of Public Aid (now Department
5of Healthcare and Family Services) shall develop a plan for
6prenatal and perinatal preventive health care and shall present
7the plan to the General Assembly by January 1, 2004. On or
8before January 1, 2006 and every 2 years thereafter, the
9Department shall report to the General Assembly concerning the
10effectiveness of prenatal and perinatal health care services
11reimbursed under this Section in preventing low-birthweight
12infants and reducing the need for neonatal intensive care
13hospital services. Each such report shall include an evaluation
14of how the ratio of expenditures for treating low-birthweight
15infants compared with the investment in promoting healthy
16births and infants in local community areas throughout Illinois
17relates to healthy infant development in those areas.
18    On and after July 1, 2012, the Department shall reduce any
19rate of reimbursement for services or other payments or alter
20any methodologies authorized by this Code to reduce any rate of
21reimbursement for services or other payments in accordance with
22Section 5-5e.
23(Source: P.A. 95-331, eff. 8-21-07.)
 
24    (305 ILCS 5/5-5.25)
25    Sec. 5-5.25. Access to psychiatric mental health services.

 

 

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1The General Assembly finds that providing access to psychiatric
2mental health services in a timely manner will improve the
3quality of life for persons suffering from mental illness and
4will contain health care costs by avoiding the need for more
5costly inpatient hospitalization. The Department of Healthcare
6and Family Services shall reimburse psychiatrists and
7federally qualified health centers as defined in Section
81905(l)(2)(B) of the federal Social Security Act for mental
9health services provided by psychiatrists, as authorized by
10Illinois law, to recipients via telepsychiatry. The
11Department, by rule, shall establish (i) criteria for such
12services to be reimbursed, including appropriate facilities
13and equipment to be used at both sites and requirements for a
14physician or other licensed health care professional to be
15present at the site where the patient is located, and (ii) a
16method to reimburse providers for mental health services
17provided by telepsychiatry.
18    On and after July 1, 2012, the Department shall reduce any
19rate of reimbursement for services or other payments or alter
20any methodologies authorized by this Code to reduce any rate of
21reimbursement for services or other payments in accordance with
22Section 5-5e.
23(Source: P.A. 95-16, eff. 7-18-07.)
 
24    (305 ILCS 5/5-5e new)
25    Sec. 5-5e. Adjusted rates of reimbursement.

 

 

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1    (a) Rates or payments for services in effect on June 30,
22012 shall be adjusted and services shall be affected as
3required by any other provision of this amendatory Act of the
497th General Assembly. In addition, the Department shall do the
5following:
6        (1) Delink the per diem rate paid for supportive living
7    facility services from the per diem rate paid for nursing
8    facility services, effective for services provided on or
9    after May 1, 2011.
10        (2) Cease payment for bed reserves in nursing
11    facilities, specialized mental health rehabilitation
12    facilities, and, except in the instance of residents who
13    are under 21 years of age, intermediate care facilities for
14    persons with developmental disabilities.
15        (3) Cease payment of the $10 per day add-on payment to
16    nursing facilities for certain residents with
17    developmental disabilities.
18    (b) After the application of subsection (a),
19notwithstanding any other provision of this Code to the
20contrary and to the extent permitted by federal law, on and
21after July 1, 2012, the rates of reimbursement for services and
22other payments provided under this Code shall further be
23reduced as follows:
24        (1) Rates or payments for physician services, dental
25    services, or community health center services reimbursed
26    through an encounter rate, and services provided under the

 

 

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1    Medicaid Rehabilitation Option of the Illinois Title XIX
2    State Plan shall not be further reduced.
3        (2) Rates or payments, or the portion thereof, paid to
4    a provider that is operated by a unit of local government
5    or State University that provides the non-federal share of
6    such services shall not be further reduced.
7        (3) Rates or payments for hospital services delivered
8    by a hospital defined as a Safety-Net Hospital under
9    Section 5-5e.1 of this Code shall not be further reduced.
10        (4) Rates or payments for hospital services delivered
11    by a Critical Access Hospital, which is an Illinois
12    hospital designated as a critical care hospital by the
13    Department of Public Health in accordance with 42 CFR 485,
14    Subpart F, shall not be further reduced.
15        (5) Rates or payments for Nursing Facility Services
16    shall only be further adjusted pursuant to Section 5-5.2 of
17    this Code.
18        (6) Rates or payments for services delivered by long
19    term care facilities licensed under the ID/DD Community
20    Care Act and developmental training services shall not be
21    further reduced.
22        (7) Rates or payments for services provided under
23    capitation rates shall be adjusted taking into
24    consideration the rates reduction and covered services
25    required by this amendatory Act of the 97th General
26    Assembly.

 

 

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1        (8) For hospitals not previously described in this
2    subsection, the rates or payments for hospital services
3    shall be further reduced by 3.5%, except for payments
4    authorized under Section 5A-12.4 of this Code.
5        (9) For all other rates or payments for services
6    delivered by providers not specifically referenced in
7    paragraphs (1) through (8), rates or payments shall be
8    further reduced by 2.7%.
9    (c) Any assessment imposed by this Code shall continue and
10nothing in this Section shall be construed to cause it to
11cease.
 
12    (305 ILCS 5/5-5e.1 new)
13    Sec. 5-5e.1. Safety-Net Hospitals.
14    (a) A Safety-Net Hospital is an Illinois hospital that:
15        (1) is licensed by the Department of Public Health as a
16    general acute care or pediatric hospital; and
17        (2) is a disproportionate share hospital, as described
18    in Section 1923 of the federal Social Security Act, as
19    determined by the Department; and
20        (3) meets one of the following:
21            (A) has a MIUR of at least 40% and a charity
22        percent of at least 4%; or
23            (B) has a MIUR of at least 50%.
24    (b) Definitions. As used in this Section:
25        (1) "Charity percent" means the ratio of (i) the

 

 

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1    hospital's charity charges for services provided to
2    individuals without health insurance or another source of
3    third party coverage to (ii) the Illinois total hospital
4    charges, each as reported on the hospital's OBRA form.
5        (2) "MIUR" means Medicaid Inpatient Utilization Rate
6    and is defined as a fraction, the numerator of which is the
7    number of a hospital's inpatient days provided in the
8    hospital's fiscal year ending 3 years prior to the rate
9    year, to patients who, for such days, were eligible for
10    Medicaid under Title XIX of the federal Social Security
11    Act, 42 USC 1396a et seq., and the denominator of which is
12    the total number of the hospital's inpatient days in that
13    same period.
14        (3) "OBRA form" means form HFS-3834, OBRA '93 data
15    collection form, for the rate year.
16        (4) "Rate year" means the 12-month period beginning on
17    October 1.
18    (c) For the 27-month period beginning July 1, 2012, a
19hospital that would have qualified for the rate year beginning
20October 1, 2011, shall be a Safety-Net Hospital.
21    (d) No later than August 15 preceding the rate year, each
22hospital shall submit the OBRA form to the Department. Prior to
23October 1, the Department shall notify each hospital whether it
24has qualified as a Safety-Net Hospital.
25    (e) The Department may promulgate rules in order to
26implement this Section.
 

 

 

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1    (305 ILCS 5/5-5f new)
2    Sec. 5-5f. Elimination and limitations of medical
3assistance services. Notwithstanding any other provision of
4this Code to the contrary, on and after July 1, 2012:
5    (a) The following services shall no longer be a covered
6service available under this Code: group psychotherapy for
7residents of any facility licensed under the Nursing Home Care
8Act or the Specialized Mental Health Rehabilitation Act; and
9adult chiropractic services.
10    (b) The Department shall place the following limitations on
11services: (i) the Department shall limit adult eyeglasses to
12one pair every 2 years; (ii) the Department shall set an annual
13limit of a maximum of 20 visits for each of the following
14services: adult speech, hearing, and language therapy
15services, adult occupational therapy services, and physical
16therapy services; (iii) the Department shall limit podiatry
17services to individuals with diabetes; (iv) the Department
18shall pay for caesarean sections at the normal vaginal delivery
19rate unless a caesarean section was medically necessary; (v)
20the Department shall limit adult dental services to
21emergencies; and (vi) effective July 1, 2012, the Department
22shall place limitations and require concurrent review on every
23inpatient detoxification stay to prevent repeat admissions to
24any hospital for detoxification within 60 days of a previous
25inpatient detoxification stay. The Department shall convene a

 

 

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1workgroup of hospitals, substance abuse providers, care
2coordination entities, managed care plans, and other
3stakeholders to develop recommendations for quality standards,
4diversion to other settings, and admission criteria for
5patients who need inpatient detoxification.
6    (c) The Department shall require prior approval of the
7following services: wheelchair repairs, regardless of the cost
8of the repairs, coronary artery bypass graft, and bariatric
9surgery consistent with Medicare standards concerning patient
10responsibility. The wholesale cost of power wheelchairs shall
11be actual acquisition cost including all discounts.
12    (d) The Department shall establish benchmarks for
13hospitals to measure and align payments to reduce potentially
14preventable hospital readmissions, inpatient complications,
15and unnecessary emergency room visits. In doing so, the
16Department shall consider items, including, but not limited to,
17historic and current acuity of care and historic and current
18trends in readmission. The Department shall publish
19provider-specific historical readmission data and anticipated
20potentially preventable targets 60 days prior to the start of
21the program. In the instance of readmissions, the Department
22shall adopt policies and rates of reimbursement for services
23and other payments provided under this Code to ensure that, by
24June 30, 2013, expenditures to hospitals are reduced by, at a
25minimum, $40,000,000.
26    (e) The Department shall establish utilization controls

 

 

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1for the hospice program such that it shall not pay for other
2care services when an individual is in hospice.
3    (f) For home health services, the Department shall require
4Medicare certification of providers participating in the
5program, implement the Medicare face-to-face encounter rule,
6and limit services to post-hospitalization. The Department
7shall require providers to implement auditable electronic
8service verification based on global positioning systems or
9other cost-effective technology.
10    (g) For the Home Services Program operated by the
11Department of Human Services and the Community Care Program
12operated by the Department on Aging, the Department of Human
13Services, in cooperation with the Department on Aging, shall
14implement an electronic service verification based on global
15positioning systems or other cost-effective technology.
16    (h) The Department shall not pay for hospital admissions
17when the claim indicates a hospital acquired condition that
18would cause Medicare to reduce its payment on the claim had the
19claim been submitted to Medicare, nor shall the Department pay
20for hospital admissions where a Medicare identified "never
21event" occurred.
22    (i) The Department shall implement cost savings
23initiatives for advanced imaging services, cardiac imaging
24services, pain management services, and back surgery. Such
25initiatives shall be designed to achieve annual costs savings.
 

 

 

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1    (305 ILCS 5/5-16.7)
2    Sec. 5-16.7. Post-parturition care. The medical assistance
3program shall provide the post-parturition care benefits
4required to be covered by a policy of accident and health
5insurance under Section 356s of the Illinois Insurance Code.
6    On and after July 1, 2012, the Department shall reduce any
7rate of reimbursement for services or other payments or alter
8any methodologies authorized by this Code to reduce any rate of
9reimbursement for services or other payments in accordance with
10Section 5-5e.
11(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
 
12    (305 ILCS 5/5-16.7a)
13    Sec. 5-16.7a. Reimbursement for epidural anesthesia
14services. In addition to other procedures authorized by the
15Department under this Code, the Department shall provide
16reimbursement to medical providers for epidural anesthesia
17services when ordered by the attending practitioner at the time
18of delivery.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate of
22reimbursement for services or other payments in accordance with
23Section 5-5e.
24(Source: P.A. 93-981, eff. 8-23-04.)
 

 

 

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1    (305 ILCS 5/5-16.8)
2    Sec. 5-16.8. Required health benefits. The medical
3assistance program shall (i) provide the post-mastectomy care
4benefits required to be covered by a policy of accident and
5health insurance under Section 356t and the coverage required
6under Sections 356g.5, 356u, 356w, 356x, and 356z.6 of the
7Illinois Insurance Code and (ii) be subject to the provisions
8of Sections 356z.19 and 364.01 of the Illinois Insurance Code.
9    On and after July 1, 2012, the Department shall reduce any
10rate of reimbursement for services or other payments or alter
11any methodologies authorized by this Code to reduce any rate of
12reimbursement for services or other payments in accordance with
13Section 5-5e.
14(Source: P.A. 97-282, eff. 8-9-11.)
 
15    (305 ILCS 5/5-16.9)
16    Sec. 5-16.9. Woman's health care provider. The medical
17assistance program is subject to the provisions of Section 356r
18of the Illinois Insurance Code. The Illinois Department shall
19adopt rules to implement the requirements of Section 356r of
20the Illinois Insurance Code in the medical assistance program
21including managed care components.
22    On and after July 1, 2012, the Department shall reduce any
23rate of reimbursement for services or other payments or alter
24any methodologies authorized by this Code to reduce any rate of
25reimbursement for services or other payments in accordance with

 

 

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1Section 5-5e.
2(Source: P.A. 92-370, eff. 8-15-01.)
 
3    (305 ILCS 5/5-17)  (from Ch. 23, par. 5-17)
4    Sec. 5-17. Programs to improve access to hospital care.
5    (a) (1) The General Assembly finds:
6            (A) That while hospitals have traditionally
7        provided charitable care to indigent patients, this
8        burden is not equally borne by all hospitals operating
9        in this State. Some hospitals continue to provide
10        significant amounts of care to low-income persons
11        while others provide very little such care; and
12            (B) That access to hospital care in this State by
13        the indigent citizens of Illinois would be seriously
14        impaired by the closing of hospitals that provide
15        significant amounts of care to low-income persons.
16        (2) To help expand the availability of hospital care
17    for all citizens of this State, it is the policy of the
18    State to implement programs that more equitably distribute
19    the burden of providing hospital care to Illinois'
20    low-income population and that improve access to health
21    care in Illinois.
22        (3) The Illinois Department may develop and implement a
23    program that lessens the burden of providing hospital care
24    to Illinois' low-income population, taking into account
25    the costs that must be incurred by hospitals providing

 

 

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1    significant amounts of care to low-income persons, and may
2    develop adjustments to increase rates to improve access to
3    health care in Illinois. The Illinois Department shall
4    prescribe by rule the criteria, standards and procedures
5    for effecting such adjustments in the rates of hospital
6    payments for services provided to eligible low-income
7    persons (under Articles V, VI and VII of this Code) under
8    this Article.
9    (b) The Illinois Department shall require hospitals
10certified to participate in the federal Medicaid program to:
11        (1) provide equal access to available services to
12    low-income persons who are eligible for assistance under
13    Articles V, VI and VII of this Code;
14        (2) provide data and reports on the provision of
15    uncompensated care.
16    (c) From the effective date of this amendatory Act of 1992
17until July 1, 1992, nothing in this Section 5-17 shall be
18construed as creating a private right of action on behalf of
19any individual.
20    (d) On and after July 1, 2012, the Department shall reduce
21any rate of reimbursement for services or other payments or
22alter any methodologies authorized by this Code to reduce any
23rate of reimbursement for services or other payments in
24accordance with Section 5-5e.
25(Source: P.A. 87-13; 87-838.)
 

 

 

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1    (305 ILCS 5/5-19)  (from Ch. 23, par. 5-19)
2    Sec. 5-19. Healthy Kids Program.
3    (a) Any child under the age of 21 eligible to receive
4Medical Assistance from the Illinois Department under Article V
5of this Code shall be eligible for Early and Periodic
6Screening, Diagnosis and Treatment services provided by the
7Healthy Kids Program of the Illinois Department under the
8Social Security Act, 42 U.S.C. 1396d(r).
9    (b) Enrollment of Children in Medicaid. The Illinois
10Department shall provide for receipt and initial processing of
11applications for Medical Assistance for all pregnant women and
12children under the age of 21 at locations in addition to those
13used for processing applications for cash assistance,
14including disproportionate share hospitals, federally
15qualified health centers and other sites as selected by the
16Illinois Department.
17    (c) Healthy Kids Examinations. The Illinois Department
18shall consider any examination of a child eligible for the
19Healthy Kids services provided by a medical provider meeting
20the requirements and complying with the rules and regulations
21of the Illinois Department to be reimbursed as a Healthy Kids
22examination.
23    (d) Medical Screening Examinations.
24        (1) The Illinois Department shall insure Medicaid
25    coverage for periodic health, vision, hearing, and dental
26    screenings for children eligible for Healthy Kids services

 

 

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1    scheduled from a child's birth up until the child turns 21
2    years. The Illinois Department shall pay for vision,
3    hearing, dental and health screening examinations for any
4    child eligible for Healthy Kids services by qualified
5    providers at intervals established by Department rules.
6        (2) The Illinois Department shall pay for an
7    interperiodic health, vision, hearing, or dental screening
8    examination for any child eligible for Healthy Kids
9    services whenever an examination is:
10            (A) requested by a child's parent, guardian, or
11        custodian, or is determined to be necessary or
12        appropriate by social services, developmental, health,
13        or educational personnel; or
14            (B) necessary for enrollment in school; or
15            (C) necessary for enrollment in a licensed day care
16        program, including Head Start; or
17            (D) necessary for placement in a licensed child
18        welfare facility, including a foster home, group home
19        or child care institution; or
20            (E) necessary for attendance at a camping program;
21        or
22            (F) necessary for participation in an organized
23        athletic program; or
24            (G) necessary for enrollment in an early childhood
25        education program recognized by the Illinois State
26        Board of Education; or

 

 

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1            (H) necessary for participation in a Women,
2        Infant, and Children (WIC) program; or
3            (I) deemed appropriate by the Illinois Department.
4    (e) Minimum Screening Protocols For Periodic Health
5Screening Examinations. Health Screening Examinations must
6include the following services:
7        (1) Comprehensive Health and Development Assessment
8    including:
9            (A) Development/Mental Health/Psychosocial
10        Assessment; and
11            (B) Assessment of nutritional status including
12        tests for iron deficiency and anemia for children at
13        the following ages: 9 months, 2 years, 8 years, and 18
14        years;
15        (2) Comprehensive unclothed physical exam;
16        (3) Appropriate immunizations at a minimum, as
17    required by the Secretary of the U.S. Department of Health
18    and Human Services under 42 U.S.C. 1396d(r).
19        (4) Appropriate laboratory tests including blood lead
20    levels appropriate for age and risk factors.
21            (A) Anemia test.
22            (B) Sickle cell test.
23            (C) Tuberculin test at 12 months of age and every
24        1-2 years thereafter unless the treating health care
25        professional determines that testing is medically
26        contraindicated.

 

 

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1            (D) Other -- The Illinois Department shall insure
2        that testing for HIV, drug exposure, and sexually
3        transmitted diseases is provided for as clinically
4        indicated.
5        (5) Health Education. The Illinois Department shall
6    require providers to provide anticipatory guidance as
7    recommended by the American Academy of Pediatrics.
8        (6) Vision Screening. The Illinois Department shall
9    require providers to provide vision screenings consistent
10    with those set forth in the Department of Public Health's
11    Administrative Rules.
12        (7) Hearing Screening. The Illinois Department shall
13    require providers to provide hearing screenings consistent
14    with those set forth in the Department of Public Health's
15    Administrative Rules.
16        (8) Dental Screening. The Illinois Department shall
17    require providers to provide dental screenings consistent
18    with those set forth in the Department of Public Health's
19    Administrative Rules.
20    (f) Covered Medical Services. The Illinois Department
21shall provide coverage for all necessary health care,
22diagnostic services, treatment and other measures to correct or
23ameliorate defects, physical and mental illnesses, and
24conditions whether discovered by the screening services or not
25for all children eligible for Medical Assistance under Article
26V of this Code.

 

 

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1    (g) Notice of Healthy Kids Services.
2        (1) The Illinois Department shall inform any child
3    eligible for Healthy Kids services and the child's family
4    about the benefits provided under the Healthy Kids Program,
5    including, but not limited to, the following: what services
6    are available under Healthy Kids, including discussion of
7    the periodicity schedules and immunization schedules, that
8    services are provided at no cost to eligible children, the
9    benefits of preventive health care, where the services are
10    available, how to obtain them, and that necessary
11    transportation and scheduling assistance is available.
12        (2) The Illinois Department shall widely disseminate
13    information regarding the availability of the Healthy Kids
14    Program throughout the State by outreach activities which
15    shall include, but not be limited to, (i) the development
16    of cooperation agreements with local school districts,
17    public health agencies, clinics, hospitals and other
18    health care providers, including developmental disability
19    and mental health providers, and with charities, to notify
20    the constituents of each of the Program and assist
21    individuals, as feasible, with applying for the Program,
22    (ii) using the media for public service announcements and
23    advertisements of the Program, and (iii) developing
24    posters advertising the Program for display in hospital and
25    clinic waiting rooms.
26        (3) The Illinois Department shall utilize accepted

 

 

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1    methods for informing persons who are illiterate, blind,
2    deaf, or cannot understand the English language, including
3    but not limited to public services announcements and
4    advertisements in the foreign language media of radio,
5    television and newspapers.
6        (4) The Illinois Department shall provide notice of the
7    Healthy Kids Program to every child eligible for Healthy
8    Kids services and his or her family at the following times:
9            (A) orally by the intake worker and in writing at
10        the time of application for Medical Assistance;
11            (B) at the time the applicant is informed that he
12        or she is eligible for Medical Assistance benefits; and
13            (C) at least 20 days before the date of any
14        periodic health, vision, hearing, and dental
15        examination for any child eligible for Healthy Kids
16        services. Notice given under this subparagraph (C)
17        must state that a screening examination is due under
18        the periodicity schedules and must advise the eligible
19        child and his or her family that the Illinois
20        Department will provide assistance in scheduling an
21        appointment and arranging medical transportation.
22    (h) Data Collection. The Illinois Department shall collect
23data in a usable form to track utilization of Healthy Kids
24screening examinations by children eligible for Healthy Kids
25services, including but not limited to data showing screening
26examinations and immunizations received, a summary of

 

 

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1follow-up treatment received by children eligible for Healthy
2Kids services and the number of children receiving dental,
3hearing and vision services.
4    (i) On and after July 1, 2012, the Department shall reduce
5any rate of reimbursement for services or other payments or
6alter any methodologies authorized by this Code to reduce any
7rate of reimbursement for services or other payments in
8accordance with Section 5-5e.
9(Source: P.A. 87-630; 87-895.)
 
10    (305 ILCS 5/5-24)
11    (Section scheduled to be repealed on January 1, 2014)
12    Sec. 5-24. Disease management programs and services for
13chronic conditions; pilot project.
14    (a) In this Section, "disease management programs and
15services" means services administered to patients in order to
16improve their overall health and to prevent clinical
17exacerbations and complications, using cost-effective,
18evidence-based practice guidelines and patient self-management
19strategies. Disease management programs and services include
20all of the following:
21        (1) A population identification process.
22        (2) Evidence-based or consensus-based clinical
23    practice guidelines, risk identification, and matching of
24    interventions with clinical need.
25        (3) Patient self-management and disease education.

 

 

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1        (4) Process and outcomes measurement, evaluation,
2    management, and reporting.
3    (b) Subject to appropriations, the Department of
4Healthcare and Family Services may undertake a pilot project to
5study patient outcomes, for patients with chronic diseases or
6patients at risk of low birth weight or premature birth,
7associated with the use of disease management programs and
8services for chronic condition management. "Chronic diseases"
9include, but are not limited to, diabetes, congestive heart
10failure, and chronic obstructive pulmonary disease. Low birth
11weight and premature birth include all medical and other
12conditions that lead to poor birth outcomes or problematic
13pregnancies.
14    (c) The disease management programs and services pilot
15project shall examine whether chronic disease management
16programs and services for patients with specific chronic
17conditions do any or all of the following:
18        (1) Improve the patient's overall health in a more
19    expeditious manner.
20        (2) Lower costs in other aspects of the medical
21    assistance program, such as hospital admissions, days in
22    skilled nursing homes, emergency room visits, or more
23    frequent physician office visits.
24    (d) In carrying out the pilot project, the Department of
25Healthcare and Family Services shall examine all relevant
26scientific literature and shall consult with health care

 

 

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1practitioners including, but not limited to, physicians,
2surgeons, registered pharmacists, and registered nurses.
3    (e) The Department of Healthcare and Family Services shall
4consult with medical experts, disease advocacy groups, and
5academic institutions to develop criteria to be used in
6selecting a vendor for the pilot project.
7    (f) The Department of Healthcare and Family Services may
8adopt rules to implement this Section.
9    (g) This Section is repealed 10 years after the effective
10date of this amendatory Act of the 93rd General Assembly.
11    (h) On and after July 1, 2012, the Department shall reduce
12any rate of reimbursement for services or other payments or
13alter any methodologies authorized by this Code to reduce any
14rate of reimbursement for services or other payments in
15accordance with Section 5-5e.
16(Source: P.A. 95-331, eff. 8-21-07; 96-799, eff. 10-28-09.)
 
17    (305 ILCS 5/5-30)
18    Sec. 5-30. Care coordination.
19    (a) At least 50% of recipients eligible for comprehensive
20medical benefits in all medical assistance programs or other
21health benefit programs administered by the Department,
22including the Children's Health Insurance Program Act and the
23Covering ALL KIDS Health Insurance Act, shall be enrolled in a
24care coordination program by no later than January 1, 2015. For
25purposes of this Section, "coordinated care" or "care

 

 

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1coordination" means delivery systems where recipients will
2receive their care from providers who participate under
3contract in integrated delivery systems that are responsible
4for providing or arranging the majority of care, including
5primary care physician services, referrals from primary care
6physicians, diagnostic and treatment services, behavioral
7health services, in-patient and outpatient hospital services,
8dental services, and rehabilitation and long-term care
9services. The Department shall designate or contract for such
10integrated delivery systems (i) to ensure enrollees have a
11choice of systems and of primary care providers within such
12systems; (ii) to ensure that enrollees receive quality care in
13a culturally and linguistically appropriate manner; and (iii)
14to ensure that coordinated care programs meet the diverse needs
15of enrollees with developmental, mental health, physical, and
16age-related disabilities.
17    (b) Payment for such coordinated care shall be based on
18arrangements where the State pays for performance related to
19health care outcomes, the use of evidence-based practices, the
20use of primary care delivered through comprehensive medical
21homes, the use of electronic medical records, and the
22appropriate exchange of health information electronically made
23either on a capitated basis in which a fixed monthly premium
24per recipient is paid and full financial risk is assumed for
25the delivery of services, or through other risk-based payment
26arrangements.

 

 

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1    (c) To qualify for compliance with this Section, the 50%
2goal shall be achieved by enrolling medical assistance
3enrollees from each medical assistance enrollment category,
4including parents, children, seniors, and people with
5disabilities to the extent that current State Medicaid payment
6laws would not limit federal matching funds for recipients in
7care coordination programs. In addition, services must be more
8comprehensively defined and more risk shall be assumed than in
9the Department's primary care case management program as of the
10effective date of this amendatory Act of the 96th General
11Assembly.
12    (d) The Department shall report to the General Assembly in
13a separate part of its annual medical assistance program
14report, beginning April, 2012 until April, 2016, on the
15progress and implementation of the care coordination program
16initiatives established by the provisions of this amendatory
17Act of the 96th General Assembly. The Department shall include
18in its April 2011 report a full analysis of federal laws or
19regulations regarding upper payment limitations to providers
20and the necessary revisions or adjustments in rate
21methodologies and payments to providers under this Code that
22would be necessary to implement coordinated care with full
23financial risk by a party other than the Department.
24    (e) Integrated Care Program for individuals with chronic
25mental health conditions.
26        (1) The Integrated Care Program shall encompass

 

 

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1    services administered to recipients of medical assistance
2    under this Article to prevent exacerbations and
3    complications using cost-effective, evidence-based
4    practice guidelines and mental health management
5    strategies.
6        (2) The Department may utilize and expand upon existing
7    contractual arrangements with integrated care plans under
8    the Integrated Care Program for providing the coordinated
9    care provisions of this Section.
10        (3) Payment for such coordinated care shall be based on
11    arrangements where the State pays for performance related
12    to mental health outcomes on a capitated basis in which a
13    fixed monthly premium per recipient is paid and full
14    financial risk is assumed for the delivery of services, or
15    through other risk-based payment arrangements such as
16    provider-based care coordination.
17        (4) The Department shall examine whether chronic
18    mental health management programs and services for
19    recipients with specific chronic mental health conditions
20    do any or all of the following:
21            (A) Improve the patient's overall mental health in
22        a more expeditious and cost-effective manner.
23            (B) Lower costs in other aspects of the medical
24        assistance program, such as hospital admissions,
25        emergency room visits, or more frequent and
26        inappropriate psychotropic drug use.

 

 

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1        (5) The Department shall work with the facilities and
2    any integrated care plan participating in the program to
3    identify and correct barriers to the successful
4    implementation of this subsection (e) prior to and during
5    the implementation to best facilitate the goals and
6    objectives of this subsection (e).
7    (f) A hospital that is located in a county of the State in
8which the Department mandates some or all of the beneficiaries
9of the Medical Assistance Program residing in the county to
10enroll in a Care Coordination Program, as set forth in Section
115-30 of this Code, shall not be eligible for any non-claims
12based payments not mandated by Article V-A of this Code for
13which it would otherwise be qualified to receive, unless the
14hospital is a Coordinated Care Participating Hospital no later
15than 60 days after the effective date of this amendatory Act of
16the 97th General Assembly or 60 days after the first mandatory
17enrollment of a beneficiary in a Coordinated Care program. For
18purposes of this subsection, "Coordinated Care Participating
19Hospital" means a hospital that meets one of the following
20criteria:
21        (1) The hospital has entered into a contract to provide
22    hospital services to enrollees of the care coordination
23    program.
24        (2) The hospital has not been offered a contract by a
25    care coordination plan that pays at least as much as the
26    Department would pay, on a fee-for-service basis, not

 

 

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1    including disproportionate share hospital adjustment
2    payments or any other supplemental adjustment or add-on
3    payment to the base fee-for-service rate.
4(Source: P.A. 96-1501, eff. 1-25-11.)
 
5    (305 ILCS 5/5A-1)  (from Ch. 23, par. 5A-1)
6    Sec. 5A-1. Definitions. As used in this Article, unless
7the context requires otherwise:
8    "Adjusted gross hospital revenue" shall be determined
9separately for inpatient and outpatient services for each
10hospital conducted, operated or maintained by a hospital
11provider, and means the hospital provider's total gross
12revenues less: (i) gross revenue attributable to non-hospital
13based services including home dialysis services, durable
14medical equipment, ambulance services, outpatient clinics and
15any other non-hospital based services as determined by the
16Illinois Department by rule; and (ii) gross revenues
17attributable to the routine services provided to persons
18receiving skilled or intermediate long-term care services
19within the meaning of Title XVIII or XIX of the Social Security
20Act; and (iii) Medicare gross revenue (excluding the Medicare
21gross revenue attributable to clauses (i) and (ii) of this
22paragraph and the Medicare gross revenue attributable to the
23routine services provided to patients in a psychiatric
24hospital, a rehabilitation hospital, a distinct part
25psychiatric unit, a distinct part rehabilitation unit, or swing

 

 

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1beds). Adjusted gross hospital revenue shall be determined
2using the most recent data available from each hospital's 2003
3Medicare cost report as contained in the Healthcare Cost Report
4Information System file, for the quarter ending on December 31,
52004, without regard to any subsequent adjustments or changes
6to such data. If a hospital's 2003 Medicare cost report is not
7contained in the Healthcare Cost Report Information System, the
8hospital provider shall furnish such cost report or the data
9necessary to determine its adjusted gross hospital revenue as
10required by rule by the Illinois Department.
11    "Fund" means the Hospital Provider Fund.
12    "Hospital" means an institution, place, building, or
13agency located in this State that is subject to licensure by
14the Illinois Department of Public Health under the Hospital
15Licensing Act, whether public or private and whether organized
16for profit or not-for-profit.
17    "Hospital provider" means a person licensed by the
18Department of Public Health to conduct, operate, or maintain a
19hospital, regardless of whether the person is a Medicaid
20provider. For purposes of this paragraph, "person" means any
21political subdivision of the State, municipal corporation,
22individual, firm, partnership, corporation, company, limited
23liability company, association, joint stock association, or
24trust, or a receiver, executor, trustee, guardian, or other
25representative appointed by order of any court.
26    "Medicare bed days" means, for each hospital, the sum of

 

 

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1the number of days that each bed was occupied by a patient who
2was covered by Title XVIII of the Social Security Act,
3excluding days attributable to the routine services provided to
4persons receiving skilled or intermediate long term care
5services. Medicare bed days shall be computed separately for
6each hospital operated or maintained by a hospital provider.
7    "Occupied bed days" means the sum of the number of days
8that each bed was occupied by a patient for all beds, excluding
9days attributable to the routine services provided to persons
10receiving skilled or intermediate long term care services.
11Occupied bed days shall be computed separately for each
12hospital operated or maintained by a hospital provider.
13    "Proration factor" means a fraction, the numerator of which
14is 53 and the denominator of which is 365.
15(Source: P.A. 94-242, eff. 7-18-05; 95-859, eff. 8-19-08.)
 
16    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
17    (Section scheduled to be repealed on July 1, 2014)
18    Sec. 5A-2. Assessment.
19    (a) Subject to Sections 5A-3 and 5A-10, an annual
20assessment on inpatient services is imposed on each hospital
21provider in an amount equal to the hospital's occupied bed days
22multiplied by $84.19 multiplied by the proration factor for
23State fiscal year 2004 and the hospital's occupied bed days
24multiplied by $84.19 for State fiscal year 2005.
25    For State fiscal years 2004 and 2005, the Department of

 

 

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1Healthcare and Family Services shall use the number of occupied
2bed days as reported by each hospital on the Annual Survey of
3Hospitals conducted by the Department of Public Health to
4calculate the hospital's annual assessment. If the sum of a
5hospital's occupied bed days is not reported on the Annual
6Survey of Hospitals or if there are data errors in the reported
7sum of a hospital's occupied bed days as determined by the
8Department of Healthcare and Family Services (formerly
9Department of Public Aid), then the Department of Healthcare
10and Family Services may obtain the sum of occupied bed days
11from any source available, including, but not limited to,
12records maintained by the hospital provider, which may be
13inspected at all times during business hours of the day by the
14Department of Healthcare and Family Services or its duly
15authorized agents and employees.
16    Subject to Sections 5A-3 and 5A-10, for the privilege of
17engaging in the occupation of hospital provider, beginning
18August 1, 2005, an annual assessment is imposed on each
19hospital provider for State fiscal years 2006, 2007, and 2008,
20in an amount equal to 2.5835% of the hospital provider's
21adjusted gross hospital revenue for inpatient services and
222.5835% of the hospital provider's adjusted gross hospital
23revenue for outpatient services. If the hospital provider's
24adjusted gross hospital revenue is not available, then the
25Illinois Department may obtain the hospital provider's
26adjusted gross hospital revenue from any source available,

 

 

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1including, but not limited to, records maintained by the
2hospital provider, which may be inspected at all times during
3business hours of the day by the Illinois Department or its
4duly authorized agents and employees.
5    Subject to Sections 5A-3 and 5A-10, for State fiscal years
62009 through 2014 and July 1, 2014 through December 31, 2014,
7an annual assessment on inpatient services is imposed on each
8hospital provider in an amount equal to $218.38 multiplied by
9the difference of the hospital's occupied bed days less the
10hospital's Medicare bed days.
11    For State fiscal years 2009 through 2014 and after, a
12hospital's occupied bed days and Medicare bed days shall be
13determined using the most recent data available from each
14hospital's 2005 Medicare cost report as contained in the
15Healthcare Cost Report Information System file, for the quarter
16ending on December 31, 2006, without regard to any subsequent
17adjustments or changes to such data. If a hospital's 2005
18Medicare cost report is not contained in the Healthcare Cost
19Report Information System, then the Illinois Department may
20obtain the hospital provider's occupied bed days and Medicare
21bed days from any source available, including, but not limited
22to, records maintained by the hospital provider, which may be
23inspected at all times during business hours of the day by the
24Illinois Department or its duly authorized agents and
25employees.
26    (b) (Blank).

 

 

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1    (c) (Blank).
2    (d) Notwithstanding any of the other provisions of this
3Section, the Department is authorized, during this 94th General
4Assembly, to adopt rules to reduce the rate of any annual
5assessment imposed under this Section, as authorized by Section
65-46.2 of the Illinois Administrative Procedure Act.
7    (e) Notwithstanding any other provision of this Section,
8any plan providing for an assessment on a hospital provider as
9a permissible tax under Title XIX of the federal Social
10Security Act and Medicaid-eligible payments to hospital
11providers from the revenues derived from that assessment shall
12be reviewed by the Illinois Department of Healthcare and Family
13Services, as the Single State Medicaid Agency required by
14federal law, to determine whether those assessments and
15hospital provider payments meet federal Medicaid standards. If
16the Department determines that the elements of the plan may
17meet federal Medicaid standards and a related State Medicaid
18Plan Amendment is prepared in a manner and form suitable for
19submission, that State Plan Amendment shall be submitted in a
20timely manner for review by the Centers for Medicare and
21Medicaid Services of the United States Department of Health and
22Human Services and subject to approval by the Centers for
23Medicare and Medicaid Services of the United States Department
24of Health and Human Services. No such plan shall become
25effective without approval by the Illinois General Assembly by
26the enactment into law of related legislation. Notwithstanding

 

 

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1any other provision of this Section, the Department is
2authorized to adopt rules to reduce the rate of any annual
3assessment imposed under this Section. Any such rules may be
4adopted by the Department under Section 5-50 of the Illinois
5Administrative Procedure Act.
6(Source: P.A. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
 
7    (305 ILCS 5/5A-3)  (from Ch. 23, par. 5A-3)
8    Sec. 5A-3. Exemptions.
9    (a) (Blank).
10    (b) A hospital provider that is a State agency, a State
11university, or a county with a population of 3,000,000 or more
12is exempt from the assessment imposed by Section 5A-2.
13    (b-2) A hospital provider that is a county with a
14population of less than 3,000,000 or a township, municipality,
15hospital district, or any other local governmental unit is
16exempt from the assessment imposed by Section 5A-2.
17    (b-5) (Blank).
18    (b-10) (Blank). For State fiscal years 2004 through 2014, a
19hospital provider, described in Section 1903(w)(3)(F) of the
20Social Security Act, whose hospital does not charge for its
21services is exempt from the assessment imposed by Section 5A-2,
22unless the exemption is adjudged to be unconstitutional or
23otherwise invalid, in which case the hospital provider shall
24pay the assessment imposed by Section 5A-2.
25    (b-15) (Blank). For State fiscal years 2004 and 2005, a

 

 

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1hospital provider whose hospital is licensed by the Department
2of Public Health as a psychiatric hospital is exempt from the
3assessment imposed by Section 5A-2, unless the exemption is
4adjudged to be unconstitutional or otherwise invalid, in which
5case the hospital provider shall pay the assessment imposed by
6Section 5A-2.
7    (b-20) (Blank). For State fiscal years 2004 and 2005, a
8hospital provider whose hospital is licensed by the Department
9of Public Health as a rehabilitation hospital is exempt from
10the assessment imposed by Section 5A-2, unless the exemption is
11adjudged to be unconstitutional or otherwise invalid, in which
12case the hospital provider shall pay the assessment imposed by
13Section 5A-2.
14    (b-25) (Blank). For State fiscal years 2004 and 2005, a
15hospital provider whose hospital (i) is not a psychiatric
16hospital, rehabilitation hospital, or children's hospital and
17(ii) has an average length of inpatient stay greater than 25
18days is exempt from the assessment imposed by Section 5A-2,
19unless the exemption is adjudged to be unconstitutional or
20otherwise invalid, in which case the hospital provider shall
21pay the assessment imposed by Section 5A-2.
22    (c) (Blank).
23(Source: P.A. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
 
24    (305 ILCS 5/5A-4)  (from Ch. 23, par. 5A-4)
25    Sec. 5A-4. Payment of assessment; penalty.

 

 

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1    (a) The The annual assessment imposed by Section 5A-2 for
2State fiscal year 2004 shall be due and payable on June 18 of
3the year. The assessment imposed by Section 5A-2 for State
4fiscal year 2005 shall be due and payable in quarterly
5installments, each equalling one-fourth of the assessment for
6the year, on July 19, October 19, January 18, and April 19 of
7the year. The assessment imposed by Section 5A-2 for State
8fiscal years 2006 through 2008 shall be due and payable in
9quarterly installments, each equaling one-fourth of the
10assessment for the year, on the fourteenth State business day
11of September, December, March, and May. Except as provided in
12subsection (a-5) of this Section, the assessment imposed by
13Section 5A-2 for State fiscal year 2009 and each subsequent
14State fiscal year shall be due and payable in monthly
15installments, each equaling one-twelfth of the assessment for
16the year, on the fourteenth State business day of each month.
17No installment payment of an assessment imposed by Section 5A-2
18shall be due and payable, however, until after the Comptroller
19has issued the payments required under this Article. : (i) the
20Department notifies the hospital provider, in writing, that the
21payment methodologies to hospitals required under Section
225A-12, Section 5A-12.1, or Section 5A-12.2, whichever is
23applicable for that fiscal year, have been approved by the
24Centers for Medicare and Medicaid Services of the U.S.
25Department of Health and Human Services and the waiver under 42
26CFR 433.68 for the assessment imposed by Section 5A-2, if

 

 

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1necessary, has been granted by the Centers for Medicare and
2Medicaid Services of the U.S. Department of Health and Human
3Services; and (ii) the Comptroller has issued the payments
4required under Section 5A-12, Section 5A-12.1, or Section
55A-12.2, whichever is applicable for that fiscal year. Upon
6notification to the Department of approval of the payment
7methodologies required under Section 5A-12, Section 5A-12.1,
8or Section 5A-12.2, whichever is applicable for that fiscal
9year, and the waiver granted under 42 CFR 433.68, all
10installments otherwise due under Section 5A-2 prior to the date
11of notification shall be due and payable to the Department upon
12written direction from the Department and issuance by the
13Comptroller of the payments required under Section 5A-12.1 or
14Section 5A-12.2, whichever is applicable for that fiscal year.
15    (a-5) The Illinois Department may, for the purpose of
16maximizing federal revenue, accelerate the schedule upon which
17assessment installments are due and payable by hospitals with a
18payment ratio greater than or equal to one. Such acceleration
19of due dates for payment of the assessment may be made only in
20conjunction with a corresponding acceleration in access
21payments identified in Section 5A-12.2 to the same hospitals.
22For the purposes of this subsection (a-5), a hospital's payment
23ratio is defined as the quotient obtained by dividing the total
24payments for the State fiscal year, as authorized under Section
255A-12.2, by the total assessment for the State fiscal year
26imposed under Section 5A-2.

 

 

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1    (b) The Illinois Department is authorized to establish
2delayed payment schedules for hospital providers that are
3unable to make installment payments when due under this Section
4due to financial difficulties, as determined by the Illinois
5Department.
6    (c) If a hospital provider fails to pay the full amount of
7an installment when due (including any extensions granted under
8subsection (b)), there shall, unless waived by the Illinois
9Department for reasonable cause, be added to the assessment
10imposed by Section 5A-2 a penalty assessment equal to the
11lesser of (i) 5% of the amount of the installment not paid on
12or before the due date plus 5% of the portion thereof remaining
13unpaid on the last day of each 30-day period thereafter or (ii)
14100% of the installment amount not paid on or before the due
15date. For purposes of this subsection, payments will be
16credited first to unpaid installment amounts (rather than to
17penalty or interest), beginning with the most delinquent
18installments.
19    (d) Any assessment amount that is due and payable to the
20Illinois Department more frequently than once per calendar
21quarter shall be remitted to the Illinois Department by the
22hospital provider by means of electronic funds transfer. The
23Illinois Department may provide for remittance by other means
24if (i) the amount due is less than $10,000 or (ii) electronic
25funds transfer is unavailable for this purpose.
26(Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08;

 

 

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196-821, eff. 11-20-09.)
 
2    (305 ILCS 5/5A-5)  (from Ch. 23, par. 5A-5)
3    Sec. 5A-5. Notice; penalty; maintenance of records.
4    (a) The Illinois Department of Healthcare and Family
5Services shall send a notice of assessment to every hospital
6provider subject to assessment under this Article. The notice
7of assessment shall notify the hospital of its assessment and
8shall be sent after receipt by the Department of notification
9from the Centers for Medicare and Medicaid Services of the U.S.
10Department of Health and Human Services that the payment
11methodologies required under this Article Section 5A-12,
12Section 5A-12.1, or Section 5A-12.2, whichever is applicable
13for that fiscal year, and, if necessary, the waiver granted
14under 42 CFR 433.68 have been approved. The notice shall be on
15a form prepared by the Illinois Department and shall state the
16following:
17        (1) The name of the hospital provider.
18        (2) The address of the hospital provider's principal
19    place of business from which the provider engages in the
20    occupation of hospital provider in this State, and the name
21    and address of each hospital operated, conducted, or
22    maintained by the provider in this State.
23        (3) The occupied bed days, occupied bed days less
24    Medicare days, or adjusted gross hospital revenue of the
25    hospital provider (whichever is applicable), the amount of

 

 

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1    assessment imposed under Section 5A-2 for the State fiscal
2    year for which the notice is sent, and the amount of each
3    installment to be paid during the State fiscal year.
4        (4) (Blank).
5        (5) Other reasonable information as determined by the
6    Illinois Department.
7    (b) If a hospital provider conducts, operates, or maintains
8more than one hospital licensed by the Illinois Department of
9Public Health, the provider shall pay the assessment for each
10hospital separately.
11    (c) Notwithstanding any other provision in this Article, in
12the case of a person who ceases to conduct, operate, or
13maintain a hospital in respect of which the person is subject
14to assessment under this Article as a hospital provider, the
15assessment for the State fiscal year in which the cessation
16occurs shall be adjusted by multiplying the assessment computed
17under Section 5A-2 by a fraction, the numerator of which is the
18number of days in the year during which the provider conducts,
19operates, or maintains the hospital and the denominator of
20which is 365. Immediately upon ceasing to conduct, operate, or
21maintain a hospital, the person shall pay the assessment for
22the year as so adjusted (to the extent not previously paid).
23    (d) Notwithstanding any other provision in this Article, a
24provider who commences conducting, operating, or maintaining a
25hospital, upon notice by the Illinois Department, shall pay the
26assessment computed under Section 5A-2 and subsection (e) in

 

 

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1installments on the due dates stated in the notice and on the
2regular installment due dates for the State fiscal year
3occurring after the due dates of the initial notice.
4    (e) Notwithstanding any other provision in this Article,
5for State fiscal years 2004 and 2005, in the case of a hospital
6provider that did not conduct, operate, or maintain a hospital
7throughout calendar year 2001, the assessment for that State
8fiscal year shall be computed on the basis of hypothetical
9occupied bed days for the full calendar year as determined by
10the Illinois Department. Notwithstanding any other provision
11in this Article, for State fiscal years 2006 through 2008, in
12the case of a hospital provider that did not conduct, operate,
13or maintain a hospital in 2003, the assessment for that State
14fiscal year shall be computed on the basis of hypothetical
15adjusted gross hospital revenue for the hospital's first full
16fiscal year as determined by the Illinois Department (which may
17be based on annualization of the provider's actual revenues for
18a portion of the year, or revenues of a comparable hospital for
19the year, including revenues realized by a prior provider of
20the same hospital during the year). Notwithstanding any other
21provision in this Article, for State fiscal years 2009 through
222015 2014, in the case of a hospital provider that did not
23conduct, operate, or maintain a hospital in 2005, the
24assessment for that State fiscal year shall be computed on the
25basis of hypothetical occupied bed days for the full calendar
26year as determined by the Illinois Department.

 

 

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1    (f) Every hospital provider subject to assessment under
2this Article shall keep sufficient records to permit the
3determination of adjusted gross hospital revenue for the
4hospital's fiscal year. All such records shall be kept in the
5English language and shall, at all times during regular
6business hours of the day, be subject to inspection by the
7Illinois Department or its duly authorized agents and
8employees.
9    (g) The Illinois Department may, by rule, provide a
10hospital provider a reasonable opportunity to request a
11clarification or correction of any clerical or computational
12errors contained in the calculation of its assessment, but such
13corrections shall not extend to updating the cost report
14information used to calculate the assessment.
15    (h) (Blank).
16(Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08;
1796-1530, eff. 2-16-11.)
 
18    (305 ILCS 5/5A-6)  (from Ch. 23, par. 5A-6)
19    Sec. 5A-6. Disposition of proceeds. The Illinois
20Department shall deposit pay all moneys received from hospital
21providers under this Article into the Hospital Provider Fund.
22Upon certification by the Illinois Department to the State
23Comptroller of its intent to withhold payments from a provider
24pursuant to under Section 5A-7(b), the State Comptroller shall
25draw a warrant on the treasury or other fund held by the State

 

 

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1Treasurer, as appropriate. The warrant shall state the amount
2for which the provider is entitled to a warrant, the amount of
3the deduction, and the reason therefor and shall direct the
4State Treasurer to pay the balance to the provider, all in
5accordance with Section 10.05 of the State Comptroller Act. The
6warrant also shall direct the State Treasurer to transfer the
7amount of the deduction so ordered from the treasury or other
8fund into the Hospital Provider Fund.
9(Source: P.A. 87-861.)
 
10    (305 ILCS 5/5A-8)  (from Ch. 23, par. 5A-8)
11    Sec. 5A-8. Hospital Provider Fund.
12    (a) There is created in the State Treasury the Hospital
13Provider Fund. Interest earned by the Fund shall be credited to
14the Fund. The Fund shall not be used to replace any moneys
15appropriated to the Medicaid program by the General Assembly.
16    (b) The Fund is created for the purpose of receiving moneys
17in accordance with Section 5A-6 and disbursing moneys only for
18the following purposes, notwithstanding any other provision of
19law:
20        (1) For making payments to hospitals as required under
21    Articles V, V-A, VI, and XIV of this Code, under the
22    Children's Health Insurance Program Act, under the
23    Covering ALL KIDS Health Insurance Act, and under the Long
24    Term Acute Care Hospital Quality Improvement Transfer
25    Program Act. Senior Citizens and Disabled Persons Property

 

 

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1    Tax Relief and Pharmaceutical Assistance Act.
2        (2) For the reimbursement of moneys collected by the
3    Illinois Department from hospitals or hospital providers
4    through error or mistake in performing the activities
5    authorized under this Article and Article V of this Code.
6        (3) For payment of administrative expenses incurred by
7    the Illinois Department or its agent in performing the
8    activities under authorized by this Code, the Children's
9    Health Insurance Program Act, the Covering ALL KIDS Health
10    Insurance Act, and the Long Term Acute Care Hospital
11    Quality Improvement Transfer Program Act. Article.
12        (4) For payments of any amounts which are reimbursable
13    to the federal government for payments from this Fund which
14    are required to be paid by State warrant.
15        (5) For making transfers, as those transfers are
16    authorized in the proceedings authorizing debt under the
17    Short Term Borrowing Act, but transfers made under this
18    paragraph (5) shall not exceed the principal amount of debt
19    issued in anticipation of the receipt by the State of
20    moneys to be deposited into the Fund.
21        (6) For making transfers to any other fund in the State
22    treasury, but transfers made under this paragraph (6) shall
23    not exceed the amount transferred previously from that
24    other fund into the Hospital Provider Fund plus any
25    interest that would have been earned by that fund on the
26    monies that had been transferred.

 

 

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1        (6.5) For making transfers to the Healthcare Provider
2    Relief Fund, except that transfers made under this
3    paragraph (6.5) shall not exceed $60,000,000 in the
4    aggregate.
5        (7) For making transfers not exceeding the following
6    amounts, in each State fiscal year during which an
7    assessment is imposed pursuant to Section 5A-2, to the
8    following designated funds:
9            Health and Human Services Medicaid Trust
10                Fund..............................$20,000,000
11            Long-Term Care Provider Fund..........$30,000,000
12            General Revenue Fund.................$80,000,000.
13    Transfers under this paragraph shall be made within 7 days
14after the payments have been received pursuant to the schedule
15of payments provided in subsection (a) of Section 5A-4. For
16State fiscal years 2004 and 2005 for making transfers to the
17Health and Human Services Medicaid Trust Fund, including 20% of
18the moneys received from hospital providers under Section 5A-4
19and transferred into the Hospital Provider Fund under Section
205A-6. For State fiscal year 2006 for making transfers to the
21Health and Human Services Medicaid Trust Fund of up to
22$130,000,000 per year of the moneys received from hospital
23providers under Section 5A-4 and transferred into the Hospital
24Provider Fund under Section 5A-6. Transfers under this
25paragraph shall be made within 7 days after the payments have
26been received pursuant to the schedule of payments provided in

 

 

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1subsection (a) of Section 5A-4.
2        (7.5) (Blank). For State fiscal year 2007 for making
3    transfers of the moneys received from hospital providers
4    under Section 5A-4 and transferred into the Hospital
5    Provider Fund under Section 5A-6 to the designated funds
6    not exceeding the following amounts in that State fiscal
7    year:
8        Health and Human Services
9            Medicaid Trust Fund.............................. $20,000,000
10        Long-Term Care Provider Fund............ $30,000,000
11        General Revenue Fund................... $80,000,000.
12        Transfers under this paragraph shall be made within 7
13    days after the payments have been received pursuant to the
14    schedule of payments provided in subsection (a) of Section
15    5A-4.
16        (7.8) (Blank). For State fiscal year 2008, for making
17    transfers of the moneys received from hospital providers
18    under Section 5A-4 and transferred into the Hospital
19    Provider Fund under Section 5A-6 to the designated funds
20    not exceeding the following amounts in that State fiscal
21    year:
22        Health and Human Services
23            Medicaid Trust Fund..................$40,000,000
24        Long-Term Care Provider Fund..............$60,000,000
25        General Revenue Fund....................$160,000,000.
26        Transfers under this paragraph shall be made within 7

 

 

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1    days after the payments have been received pursuant to the
2    schedule of payments provided in subsection (a) of Section
3    5A-4.
4        (7.9) (Blank). For State fiscal years 2009 through
5    2014, for making transfers of the moneys received from
6    hospital providers under Section 5A-4 and transferred into
7    the Hospital Provider Fund under Section 5A-6 to the
8    designated funds not exceeding the following amounts in
9    that State fiscal year:
10        Health and Human Services
11            Medicaid Trust Fund...................$20,000,000
12        Long Term Care Provider Fund..............$30,000,000
13        General Revenue Fund.....................$80,000,000.
14        Except as provided under this paragraph, transfers
15    under this paragraph shall be made within 7 business days
16    after the payments have been received pursuant to the
17    schedule of payments provided in subsection (a) of Section
18    5A-4. For State fiscal year 2009, transfers to the General
19    Revenue Fund under this paragraph shall be made on or
20    before June 30, 2009, as sufficient funds become available
21    in the Hospital Provider Fund to both make the transfers
22    and continue hospital payments.
23        (8) For making refunds to hospital providers pursuant
24    to Section 5A-10.
25    Disbursements from the Fund, other than transfers
26authorized under paragraphs (5) and (6) of this subsection,

 

 

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1shall be by warrants drawn by the State Comptroller upon
2receipt of vouchers duly executed and certified by the Illinois
3Department.
4    (c) The Fund shall consist of the following:
5        (1) All moneys collected or received by the Illinois
6    Department from the hospital provider assessment imposed
7    by this Article.
8        (2) All federal matching funds received by the Illinois
9    Department as a result of expenditures made by the Illinois
10    Department that are attributable to moneys deposited in the
11    Fund.
12        (3) Any interest or penalty levied in conjunction with
13    the administration of this Article.
14        (4) Moneys transferred from another fund in the State
15    treasury.
16        (5) All other moneys received for the Fund from any
17    other source, including interest earned thereon.
18    (d) (Blank).
19(Source: P.A. 95-707, eff. 1-11-08; 95-859, eff. 8-19-08; 96-3,
20eff. 2-27-09; 96-45, eff. 7-15-09; 96-821, eff. 11-20-09;
2196-1530, eff. 2-16-11.)
 
22    (305 ILCS 5/5A-10)  (from Ch. 23, par. 5A-10)
23    Sec. 5A-10. Applicability.
24    (a) The assessment imposed by Section 5A-2 shall not take
25effect or shall cease to be imposed and the Department's

 

 

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1obligation to make payments shall immediately cease, and any
2moneys remaining in the Fund shall be refunded to hospital
3providers in proportion to the amounts paid by them, if:
4        (1) The payments to hospitals required under this
5    Article are not eligible for federal matching funds under
6    Title XIX or XXI of the Social Security Act The sum of the
7    appropriations for State fiscal years 2004 and 2005 from
8    the General Revenue Fund for hospital payments under the
9    medical assistance program is less than $4,500,000,000 or
10    the appropriation for each of State fiscal years 2006, 2007
11    and 2008 from the General Revenue Fund for hospital
12    payments under the medical assistance program is less than
13    $2,500,000,000 increased annually to reflect any increase
14    in the number of recipients, or the annual appropriation
15    for State fiscal years 2009, 2010, 2011, 2013, and 2014,
16    from the General Revenue Fund combined with the Hospital
17    Provider Fund as authorized in Section 5A-8 for hospital
18    payments under the medical assistance program, is less than
19    the amount appropriated for State fiscal year 2009,
20    adjusted annually to reflect any change in the number of
21    recipients, excluding State fiscal year 2009 supplemental
22    appropriations made necessary by the enactment of the
23    American Recovery and Reinvestment Act of 2009; or
24        (2) For State fiscal years prior to State fiscal year
25    2009, the Department of Healthcare and Family Services
26    (formerly Department of Public Aid) makes changes in its

 

 

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1    rules that reduce the hospital inpatient or outpatient
2    payment rates, including adjustment payment rates, in
3    effect on October 1, 2004, except for hospitals described
4    in subsection (b) of Section 5A-3 and except for changes in
5    the methodology for calculating outlier payments to
6    hospitals for exceptionally costly stays, so long as those
7    changes do not reduce aggregate expenditures below the
8    amount expended in State fiscal year 2005 for such
9    services; or
10        (2) (2.1) For State fiscal years 2009 through 2014 and
11    July 1, 2014 through December 31, 2014, the Department of
12    Healthcare and Family Services adopts any administrative
13    rule change to reduce payment rates or alters any payment
14    methodology that reduces any payment rates made to
15    operating hospitals under the approved Title XIX or Title
16    XXI State plan in effect January 1, 2008 except for:
17            (A) any changes for hospitals described in
18        subsection (b) of Section 5A-3; or
19            (B) any rates for payments made under this Article
20        V-A; or
21            (C) any changes proposed in State plan amendment
22        transmittal numbers 08-01, 08-02, 08-04, 08-06, and
23        08-07; or
24            (D) in relation to any admissions on or after
25        January 1, 2011, a modification in the methodology for
26        calculating outlier payments to hospitals for

 

 

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1        exceptionally costly stays, for hospitals reimbursed
2        under the diagnosis-related grouping methodology in
3        effect on January 1, 2011; provided that the Department
4        shall be limited to one such modification during the
5        36-month period after the effective date of this
6        amendatory Act of the 96th General Assembly; or
7            (E) any changes affecting hospitals authorized by
8        this amendatory Act of the 97th General Assembly.
9        (3) The payments to hospitals required under Section
10    5A-12 or Section 5A-12.2 are changed or are not eligible
11    for federal matching funds under Title XIX or XXI of the
12    Social Security Act.
13    (b) The assessment imposed by Section 5A-2 shall not take
14effect or shall cease to be imposed and the Department's
15obligation to make payments shall immediately cease if the
16assessment is determined to be an impermissible tax under Title
17XIX of the Social Security Act. Moneys in the Hospital Provider
18Fund derived from assessments imposed prior thereto shall be
19disbursed in accordance with Section 5A-8 to the extent federal
20financial participation is not reduced due to the
21impermissibility of the assessments, and any remaining moneys
22shall be refunded to hospital providers in proportion to the
23amounts paid by them.
24(Source: P.A. 96-8, eff. 4-28-09; 96-1530, eff. 2-16-11; 97-72,
25eff. 7-1-11; 97-74, eff. 6-30-11.)
 

 

 

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1    (305 ILCS 5/5A-12.2)
2    (Section scheduled to be repealed on July 1, 2014)
3    Sec. 5A-12.2. Hospital access payments on or after July 1,
42008.
5    (a) To preserve and improve access to hospital services,
6for hospital services rendered on or after July 1, 2008, the
7Illinois Department shall, except for hospitals described in
8subsection (b) of Section 5A-3, make payments to hospitals as
9set forth in this Section. These payments shall be paid in 12
10equal installments on or before the seventh State business day
11of each month, except that no payment shall be due within 100
12days after the later of the date of notification of federal
13approval of the payment methodologies required under this
14Section or any waiver required under 42 CFR 433.68, at which
15time the sum of amounts required under this Section prior to
16the date of notification is due and payable. Payments under
17this Section are not due and payable, however, until (i) the
18methodologies described in this Section are approved by the
19federal government in an appropriate State Plan amendment and
20(ii) the assessment imposed under this Article is determined to
21be a permissible tax under Title XIX of the Social Security
22Act.
23    (a-5) The Illinois Department may, when practicable,
24accelerate the schedule upon which payments authorized under
25this Section are made.
26    (b) Across-the-board inpatient adjustment.

 

 

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1        (1) In addition to rates paid for inpatient hospital
2    services, the Department shall pay to each Illinois general
3    acute care hospital an amount equal to 40% of the total
4    base inpatient payments paid to the hospital for services
5    provided in State fiscal year 2005.
6        (2) In addition to rates paid for inpatient hospital
7    services, the Department shall pay to each freestanding
8    Illinois specialty care hospital as defined in 89 Ill. Adm.
9    Code 149.50(c)(1), (2), or (4) an amount equal to 60% of
10    the total base inpatient payments paid to the hospital for
11    services provided in State fiscal year 2005.
12        (3) In addition to rates paid for inpatient hospital
13    services, the Department shall pay to each freestanding
14    Illinois rehabilitation or psychiatric hospital an amount
15    equal to $1,000 per Medicaid inpatient day multiplied by
16    the increase in the hospital's Medicaid inpatient
17    utilization ratio (determined using the positive
18    percentage change from the rate year 2005 Medicaid
19    inpatient utilization ratio to the rate year 2007 Medicaid
20    inpatient utilization ratio, as calculated by the
21    Department for the disproportionate share determination).
22        (4) In addition to rates paid for inpatient hospital
23    services, the Department shall pay to each Illinois
24    children's hospital an amount equal to 20% of the total
25    base inpatient payments paid to the hospital for services
26    provided in State fiscal year 2005 and an additional amount

 

 

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1    equal to 20% of the base inpatient payments paid to the
2    hospital for psychiatric services provided in State fiscal
3    year 2005.
4        (5) In addition to rates paid for inpatient hospital
5    services, the Department shall pay to each Illinois
6    hospital eligible for a pediatric inpatient adjustment
7    payment under 89 Ill. Adm. Code 148.298, as in effect for
8    State fiscal year 2007, a supplemental pediatric inpatient
9    adjustment payment equal to:
10            (i) For freestanding children's hospitals as
11        defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5
12        multiplied by the hospital's pediatric inpatient
13        adjustment payment required under 89 Ill. Adm. Code
14        148.298, as in effect for State fiscal year 2008.
15            (ii) For hospitals other than freestanding
16        children's hospitals as defined in 89 Ill. Adm. Code
17        149.50(c)(3)(B), 1.0 multiplied by the hospital's
18        pediatric inpatient adjustment payment required under
19        89 Ill. Adm. Code 148.298, as in effect for State
20        fiscal year 2008.
21    (c) Outpatient adjustment.
22        (1) In addition to the rates paid for outpatient
23    hospital services, the Department shall pay each Illinois
24    hospital an amount equal to 2.2 multiplied by the
25    hospital's ambulatory procedure listing payments for
26    categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code

 

 

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1    148.140(b), for State fiscal year 2005.
2        (2) In addition to the rates paid for outpatient
3    hospital services, the Department shall pay each Illinois
4    freestanding psychiatric hospital an amount equal to 3.25
5    multiplied by the hospital's ambulatory procedure listing
6    payments for category 5b, as defined in 89 Ill. Adm. Code
7    148.140(b)(1)(E), for State fiscal year 2005.
8    (d) Medicaid high volume adjustment. In addition to rates
9paid for inpatient hospital services, the Department shall pay
10to each Illinois general acute care hospital that provided more
11than 20,500 Medicaid inpatient days of care in State fiscal
12year 2005 amounts as follows:
13        (1) For hospitals with a case mix index equal to or
14    greater than the 85th percentile of hospital case mix
15    indices, $350 for each Medicaid inpatient day of care
16    provided during that period; and
17        (2) For hospitals with a case mix index less than the
18    85th percentile of hospital case mix indices, $100 for each
19    Medicaid inpatient day of care provided during that period.
20    (e) Capital adjustment. In addition to rates paid for
21inpatient hospital services, the Department shall pay an
22additional payment to each Illinois general acute care hospital
23that has a Medicaid inpatient utilization rate of at least 10%
24(as calculated by the Department for the rate year 2007
25disproportionate share determination) amounts as follows:
26        (1) For each Illinois general acute care hospital that

 

 

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1    has a Medicaid inpatient utilization rate of at least 10%
2    and less than 36.94% and whose capital cost is less than
3    the 60th percentile of the capital costs of all Illinois
4    hospitals, the amount of such payment shall equal the
5    hospital's Medicaid inpatient days multiplied by the
6    difference between the capital costs at the 60th percentile
7    of the capital costs of all Illinois hospitals and the
8    hospital's capital costs.
9        (2) For each Illinois general acute care hospital that
10    has a Medicaid inpatient utilization rate of at least
11    36.94% and whose capital cost is less than the 75th
12    percentile of the capital costs of all Illinois hospitals,
13    the amount of such payment shall equal the hospital's
14    Medicaid inpatient days multiplied by the difference
15    between the capital costs at the 75th percentile of the
16    capital costs of all Illinois hospitals and the hospital's
17    capital costs.
18    (f) Obstetrical care adjustment.
19        (1) In addition to rates paid for inpatient hospital
20    services, the Department shall pay $1,500 for each Medicaid
21    obstetrical day of care provided in State fiscal year 2005
22    by each Illinois rural hospital that had a Medicaid
23    obstetrical percentage (Medicaid obstetrical days divided
24    by Medicaid inpatient days) greater than 15% for State
25    fiscal year 2005.
26        (2) In addition to rates paid for inpatient hospital

 

 

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1    services, the Department shall pay $1,350 for each Medicaid
2    obstetrical day of care provided in State fiscal year 2005