Sen. Ann Gillespie

Filed: 4/7/2022

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 4343

2    AMENDMENT NO. ______. Amend House Bill 4343 by replacing
3everything after the enacting clause with the following:
 
4
"ARTICLE 1.

 
5    "Section 1-1. Short title. This Article may be cited as
6the Wellness Checks in Schools Program Act. References in this
7Article to "this Act" mean this Article.
 
8    Section 1-5. Findings. The General Assembly finds that:
9        (1) Depression is the most common mental health
10    disorder among American teens and adults, with over
11    2,800,000 young people between the ages of 12 and 17
12    experiencing at least one major depressive episode each
13    year, approximately 10-15% of teenagers exhibiting at
14    least one symptom of depression at any time, and roughly
15    5% of teenagers suffering from major depression at any

 

 

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1    time. Teenage depression is 2 to 3 times more common in
2    females than in males.
3        (2) Various biological, psychological, and
4    environmental risk factors may contribute to teenage
5    depression, which can lead to substance and alcohol abuse,
6    social isolation, poor academic and workplace performance,
7    unnecessary risk taking, early pregnancy, and suicide,
8    which is the second leading cause of death among
9    teenagers. Approximately 20% of teens with depression
10    seriously consider suicide, and one in 12 attempt suicide.
11    Untreated teenage depression can also result in adverse
12    consequences throughout adulthood.
13        (3) Most teens who experience depression suffer from
14    more than one episode. It is estimated that, although
15    teenage depression is highly treatable through
16    combinations of therapy, individual and group counseling,
17    and certain medications, fewer than one-third of teenagers
18    experiencing depression seek help or treatment.
19        (4) The proper detection and diagnosis of mental
20    health conditions, including depression, is a key element
21    in reducing the risk of teenage suicide and improving
22    physical and mental health outcomes for young people. It
23    is therefore fitting and appropriate to establish
24    school-based mental health screenings to help identify the
25    symptoms of mental health conditions and facilitate access
26    to appropriate treatment.
 

 

 

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1    Section 1-10. Wellness Checks in Schools Collaborative.
2    (a) Subject to appropriation, the Department of Healthcare
3and Family Services shall establish the Wellness Checks in
4Schools Collaborative for school districts that wish to
5implement wellness checks to identify students in grades 7
6through 12 who are at risk of mental health conditions,
7including depression or other mental health issues. The
8Department shall work with school districts that have a high
9percentage of students enrolled in Medicaid and a high number
10of referrals to the State's Crisis and Referral Entry Services
11(CARES) hotline.
12    (b) The Collaborative shall focus on the identification of
13research-based screening tools validated to screen for mental
14health conditions in adolescents and identification of staff
15who will be responsible for completion of the screening tool.
16Nothing in this Act prohibits a school district from using a
17self-administered screening tool as part of the wellness
18check. To assist school districts in selecting research-based
19screening tools to use in their wellness check programs, the
20Department of Healthcare and Family Services may develop a
21list of preapproved research-based screening tools that are
22validated to screen adolescents for mental health concerns and
23are appropriate for use in a school setting. The list shall be
24posted on the websites of the Department of Healthcare and
25Family Services and the State Board of Education.

 

 

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1    (c) The Collaborative shall also focus on assisting
2participating school districts in establishing a referral
3process for immediate intervention for students who are
4identified as having a behavioral health issue that requires
5intervention.
6    (d) The Department shall publish a public notice regarding
7the establishment of the Collaborative with school districts
8and shall conduct regular meetings with interested school
9districts.
10    (e) Subject to appropriation, the Department shall
11establish and implement a program to provide wellness checks
12in public schools in accordance with this Section.
 
13
ARTICLE 5.

 
14    Section 5-5. The Illinois Public Aid Code is amended by
15changing Section 14-12 as follows:
 
16    (305 ILCS 5/14-12)
17    Sec. 14-12. Hospital rate reform payment system. The
18hospital payment system pursuant to Section 14-11 of this
19Article shall be as follows:
20    (a) Inpatient hospital services. Effective for discharges
21on and after July 1, 2014, reimbursement for inpatient general
22acute care services shall utilize the All Patient Refined
23Diagnosis Related Grouping (APR-DRG) software, version 30,

 

 

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1distributed by 3MTM Health Information System.
2        (1) The Department shall establish Medicaid weighting
3    factors to be used in the reimbursement system established
4    under this subsection. Initial weighting factors shall be
5    the weighting factors as published by 3M Health
6    Information System, associated with Version 30.0 adjusted
7    for the Illinois experience.
8        (2) The Department shall establish a
9    statewide-standardized amount to be used in the inpatient
10    reimbursement system. The Department shall publish these
11    amounts on its website no later than 10 calendar days
12    prior to their effective date.
13        (3) In addition to the statewide-standardized amount,
14    the Department shall develop adjusters to adjust the rate
15    of reimbursement for critical Medicaid providers or
16    services for trauma, transplantation services, perinatal
17    care, and Graduate Medical Education (GME).
18        (4) The Department shall develop add-on payments to
19    account for exceptionally costly inpatient stays,
20    consistent with Medicare outlier principles. Outlier fixed
21    loss thresholds may be updated to control for excessive
22    growth in outlier payments no more frequently than on an
23    annual basis, but at least once every 4 years. Upon
24    updating the fixed loss thresholds, the Department shall
25    be required to update base rates within 12 months.
26        (5) The Department shall define those hospitals or

 

 

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1    distinct parts of hospitals that shall be exempt from the
2    APR-DRG reimbursement system established under this
3    Section. The Department shall publish these hospitals'
4    inpatient rates on its website no later than 10 calendar
5    days prior to their effective date.
6        (6) Beginning July 1, 2014 and ending on June 30,
7    2024, in addition to the statewide-standardized amount,
8    the Department shall develop an adjustor to adjust the
9    rate of reimbursement for safety-net hospitals defined in
10    Section 5-5e.1 of this Code excluding pediatric hospitals.
11        (7) Beginning July 1, 2014, in addition to the
12    statewide-standardized amount, the Department shall
13    develop an adjustor to adjust the rate of reimbursement
14    for Illinois freestanding inpatient psychiatric hospitals
15    that are not designated as children's hospitals by the
16    Department but are primarily treating patients under the
17    age of 21.
18        (7.5) (Blank).
19        (8) Beginning July 1, 2018, in addition to the
20    statewide-standardized amount, the Department shall adjust
21    the rate of reimbursement for hospitals designated by the
22    Department of Public Health as a Perinatal Level II or II+
23    center by applying the same adjustor that is applied to
24    Perinatal and Obstetrical care cases for Perinatal Level
25    III centers, as of December 31, 2017.
26        (9) Beginning July 1, 2018, in addition to the

 

 

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1    statewide-standardized amount, the Department shall apply
2    the same adjustor that is applied to trauma cases as of
3    December 31, 2017 to inpatient claims to treat patients
4    with burns, including, but not limited to, APR-DRGs 841,
5    842, 843, and 844.
6        (10) Beginning July 1, 2018, the
7    statewide-standardized amount for inpatient general acute
8    care services shall be uniformly increased so that base
9    claims projected reimbursement is increased by an amount
10    equal to the funds allocated in paragraph (1) of
11    subsection (b) of Section 5A-12.6, less the amount
12    allocated under paragraphs (8) and (9) of this subsection
13    and paragraphs (3) and (4) of subsection (b) multiplied by
14    40%.
15        (11) Beginning July 1, 2018, the reimbursement for
16    inpatient rehabilitation services shall be increased by
17    the addition of a $96 per day add-on.
18    (b) Outpatient hospital services. Effective for dates of
19service on and after July 1, 2014, reimbursement for
20outpatient services shall utilize the Enhanced Ambulatory
21Procedure Grouping (EAPG) software, version 3.7 distributed by
223MTM Health Information System.
23        (1) The Department shall establish Medicaid weighting
24    factors to be used in the reimbursement system established
25    under this subsection. The initial weighting factors shall
26    be the weighting factors as published by 3M Health

 

 

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1    Information System, associated with Version 3.7.
2        (2) The Department shall establish service specific
3    statewide-standardized amounts to be used in the
4    reimbursement system.
5            (A) The initial statewide standardized amounts,
6        with the labor portion adjusted by the Calendar Year
7        2013 Medicare Outpatient Prospective Payment System
8        wage index with reclassifications, shall be published
9        by the Department on its website no later than 10
10        calendar days prior to their effective date.
11            (B) The Department shall establish adjustments to
12        the statewide-standardized amounts for each Critical
13        Access Hospital, as designated by the Department of
14        Public Health in accordance with 42 CFR 485, Subpart
15        F. For outpatient services provided on or before June
16        30, 2018, the EAPG standardized amounts are determined
17        separately for each critical access hospital such that
18        simulated EAPG payments using outpatient base period
19        paid claim data plus payments under Section 5A-12.4 of
20        this Code net of the associated tax costs are equal to
21        the estimated costs of outpatient base period claims
22        data with a rate year cost inflation factor applied.
23        (3) In addition to the statewide-standardized amounts,
24    the Department shall develop adjusters to adjust the rate
25    of reimbursement for critical Medicaid hospital outpatient
26    providers or services, including outpatient high volume or

 

 

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1    safety-net hospitals. Beginning July 1, 2018, the
2    outpatient high volume adjustor shall be increased to
3    increase annual expenditures associated with this adjustor
4    by $79,200,000, based on the State Fiscal Year 2015 base
5    year data and this adjustor shall apply to public
6    hospitals, except for large public hospitals, as defined
7    under 89 Ill. Adm. Code 148.25(a).
8        (4) Beginning July 1, 2018, in addition to the
9    statewide standardized amounts, the Department shall make
10    an add-on payment for outpatient expensive devices and
11    drugs. This add-on payment shall at least apply to claim
12    lines that: (i) are assigned with one of the following
13    EAPGs: 490, 1001 to 1020, and coded with one of the
14    following revenue codes: 0274 to 0276, 0278; or (ii) are
15    assigned with one of the following EAPGs: 430 to 441, 443,
16    444, 460 to 465, 495, 496, 1090. The add-on payment shall
17    be calculated as follows: the claim line's covered charges
18    multiplied by the hospital's total acute cost to charge
19    ratio, less the claim line's EAPG payment plus $1,000,
20    multiplied by 0.8.
21        (5) Beginning July 1, 2018, the statewide-standardized
22    amounts for outpatient services shall be increased by a
23    uniform percentage so that base claims projected
24    reimbursement is increased by an amount equal to no less
25    than the funds allocated in paragraph (1) of subsection
26    (b) of Section 5A-12.6, less the amount allocated under

 

 

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1    paragraphs (8) and (9) of subsection (a) and paragraphs
2    (3) and (4) of this subsection multiplied by 46%.
3        (6) Effective for dates of service on or after July 1,
4    2018, the Department shall establish adjustments to the
5    statewide-standardized amounts for each Critical Access
6    Hospital, as designated by the Department of Public Health
7    in accordance with 42 CFR 485, Subpart F, such that each
8    Critical Access Hospital's standardized amount for
9    outpatient services shall be increased by the applicable
10    uniform percentage determined pursuant to paragraph (5) of
11    this subsection. It is the intent of the General Assembly
12    that the adjustments required under this paragraph (6) by
13    Public Act 100-1181 shall be applied retroactively to
14    claims for dates of service provided on or after July 1,
15    2018.
16        (7) Effective for dates of service on or after March
17    8, 2019 (the effective date of Public Act 100-1181), the
18    Department shall recalculate and implement an updated
19    statewide-standardized amount for outpatient services
20    provided by hospitals that are not Critical Access
21    Hospitals to reflect the applicable uniform percentage
22    determined pursuant to paragraph (5).
23            (1) Any recalculation to the
24        statewide-standardized amounts for outpatient services
25        provided by hospitals that are not Critical Access
26        Hospitals shall be the amount necessary to achieve the

 

 

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1        increase in the statewide-standardized amounts for
2        outpatient services increased by a uniform percentage,
3        so that base claims projected reimbursement is
4        increased by an amount equal to no less than the funds
5        allocated in paragraph (1) of subsection (b) of
6        Section 5A-12.6, less the amount allocated under
7        paragraphs (8) and (9) of subsection (a) and
8        paragraphs (3) and (4) of this subsection, for all
9        hospitals that are not Critical Access Hospitals,
10        multiplied by 46%.
11            (2) It is the intent of the General Assembly that
12        the recalculations required under this paragraph (7)
13        by Public Act 100-1181 shall be applied prospectively
14        to claims for dates of service provided on or after
15        March 8, 2019 (the effective date of Public Act
16        100-1181) and that no recoupment or repayment by the
17        Department or an MCO of payments attributable to
18        recalculation under this paragraph (7), issued to the
19        hospital for dates of service on or after July 1, 2018
20        and before March 8, 2019 (the effective date of Public
21        Act 100-1181), shall be permitted.
22        (8) The Department shall ensure that all necessary
23    adjustments to the managed care organization capitation
24    base rates necessitated by the adjustments under
25    subparagraph (6) or (7) of this subsection are completed
26    and applied retroactively in accordance with Section

 

 

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1    5-30.8 of this Code within 90 days of March 8, 2019 (the
2    effective date of Public Act 100-1181).
3        (9) Within 60 days after federal approval of the
4    change made to the assessment in Section 5A-2 by this
5    amendatory Act of the 101st General Assembly, the
6    Department shall incorporate into the EAPG system for
7    outpatient services those services performed by hospitals
8    currently billed through the Non-Institutional Provider
9    billing system.
10    (b-5) Notwithstanding any other provision of this Section,
11beginning with dates of service on and after January 1, 2023,
12any general acute care hospital with more than 500 outpatient
13psychiatric Medicaid services to persons under 19 years of age
14in any calendar year shall be paid the outpatient add-on
15payment of no less than $113.
16    (c) In consultation with the hospital community, the
17Department is authorized to replace 89 Ill. Admin. Code
18152.150 as published in 38 Ill. Reg. 4980 through 4986 within
1912 months of June 16, 2014 (the effective date of Public Act
2098-651). If the Department does not replace these rules within
2112 months of June 16, 2014 (the effective date of Public Act
2298-651), the rules in effect for 152.150 as published in 38
23Ill. Reg. 4980 through 4986 shall remain in effect until
24modified by rule by the Department. Nothing in this subsection
25shall be construed to mandate that the Department file a
26replacement rule.

 

 

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1    (d) Transition period. There shall be a transition period
2to the reimbursement systems authorized under this Section
3that shall begin on the effective date of these systems and
4continue until June 30, 2018, unless extended by rule by the
5Department. To help provide an orderly and predictable
6transition to the new reimbursement systems and to preserve
7and enhance access to the hospital services during this
8transition, the Department shall allocate a transitional
9hospital access pool of at least $290,000,000 annually so that
10transitional hospital access payments are made to hospitals.
11        (1) After the transition period, the Department may
12    begin incorporating the transitional hospital access pool
13    into the base rate structure; however, the transitional
14    hospital access payments in effect on June 30, 2018 shall
15    continue to be paid, if continued under Section 5A-16.
16        (2) After the transition period, if the Department
17    reduces payments from the transitional hospital access
18    pool, it shall increase base rates, develop new adjustors,
19    adjust current adjustors, develop new hospital access
20    payments based on updated information, or any combination
21    thereof by an amount equal to the decreases proposed in
22    the transitional hospital access pool payments, ensuring
23    that the entire transitional hospital access pool amount
24    shall continue to be used for hospital payments.
25    (d-5) Hospital and health care transformation program. The
26Department shall develop a hospital and health care

 

 

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1transformation program to provide financial assistance to
2hospitals in transforming their services and care models to
3better align with the needs of the communities they serve. The
4payments authorized in this Section shall be subject to
5approval by the federal government.
6        (1) Phase 1. In State fiscal years 2019 through 2020,
7    the Department shall allocate funds from the transitional
8    access hospital pool to create a hospital transformation
9    pool of at least $262,906,870 annually and make hospital
10    transformation payments to hospitals. Subject to Section
11    5A-16, in State fiscal years 2019 and 2020, an Illinois
12    hospital that received either a transitional hospital
13    access payment under subsection (d) or a supplemental
14    payment under subsection (f) of this Section in State
15    fiscal year 2018, shall receive a hospital transformation
16    payment as follows:
17            (A) If the hospital's Rate Year 2017 Medicaid
18        inpatient utilization rate is equal to or greater than
19        45%, the hospital transformation payment shall be
20        equal to 100% of the sum of its transitional hospital
21        access payment authorized under subsection (d) and any
22        supplemental payment authorized under subsection (f).
23            (B) If the hospital's Rate Year 2017 Medicaid
24        inpatient utilization rate is equal to or greater than
25        25% but less than 45%, the hospital transformation
26        payment shall be equal to 75% of the sum of its

 

 

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1        transitional hospital access payment authorized under
2        subsection (d) and any supplemental payment authorized
3        under subsection (f).
4            (C) If the hospital's Rate Year 2017 Medicaid
5        inpatient utilization rate is less than 25%, the
6        hospital transformation payment shall be equal to 50%
7        of the sum of its transitional hospital access payment
8        authorized under subsection (d) and any supplemental
9        payment authorized under subsection (f).
10        (2) Phase 2.
11            (A) The funding amount from phase one shall be
12        incorporated into directed payment and pass-through
13        payment methodologies described in Section 5A-12.7.
14            (B) Because there are communities in Illinois that
15        experience significant health care disparities due to
16        systemic racism, as recently emphasized by the
17        COVID-19 pandemic, aggravated by social determinants
18        of health and a lack of sufficiently allocated
19        healthcare resources, particularly community-based
20        services, preventive care, obstetric care, chronic
21        disease management, and specialty care, the Department
22        shall establish a health care transformation program
23        that shall be supported by the transformation funding
24        pool. It is the intention of the General Assembly that
25        innovative partnerships funded by the pool must be
26        designed to establish or improve integrated health

 

 

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1        care delivery systems that will provide significant
2        access to the Medicaid and uninsured populations in
3        their communities, as well as improve health care
4        equity. It is also the intention of the General
5        Assembly that partnerships recognize and address the
6        disparities revealed by the COVID-19 pandemic, as well
7        as the need for post-COVID care. During State fiscal
8        years 2021 through 2027, the hospital and health care
9        transformation program shall be supported by an annual
10        transformation funding pool of up to $150,000,000,
11        pending federal matching funds, to be allocated during
12        the specified fiscal years for the purpose of
13        facilitating hospital and health care transformation.
14        No disbursement of moneys for transformation projects
15        from the transformation funding pool described under
16        this Section shall be considered an award, a grant, or
17        an expenditure of grant funds. Funding agreements made
18        in accordance with the transformation program shall be
19        considered purchases of care under the Illinois
20        Procurement Code, and funds shall be expended by the
21        Department in a manner that maximizes federal funding
22        to expend the entire allocated amount.
23            The Department shall convene, within 30 days after
24        the effective date of this amendatory Act of the 101st
25        General Assembly, a workgroup that includes subject
26        matter experts on healthcare disparities and

 

 

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1        stakeholders from distressed communities, which could
2        be a subcommittee of the Medicaid Advisory Committee,
3        to review and provide recommendations on how
4        Department policy, including health care
5        transformation, can improve health disparities and the
6        impact on communities disproportionately affected by
7        COVID-19. The workgroup shall consider and make
8        recommendations on the following issues: a community
9        safety-net designation of certain hospitals, racial
10        equity, and a regional partnership to bring additional
11        specialty services to communities.
12            (C) As provided in paragraph (9) of Section 3 of
13        the Illinois Health Facilities Planning Act, any
14        hospital participating in the transformation program
15        may be excluded from the requirements of the Illinois
16        Health Facilities Planning Act for those projects
17        related to the hospital's transformation. To be
18        eligible, the hospital must submit to the Health
19        Facilities and Services Review Board approval from the
20        Department that the project is a part of the
21        hospital's transformation.
22            (D) As provided in subsection (a-20) of Section
23        32.5 of the Emergency Medical Services (EMS) Systems
24        Act, a hospital that received hospital transformation
25        payments under this Section may convert to a
26        freestanding emergency center. To be eligible for such

 

 

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1        a conversion, the hospital must submit to the
2        Department of Public Health approval from the
3        Department that the project is a part of the
4        hospital's transformation.
5            (E) Criteria for proposals. To be eligible for
6        funding under this Section, a transformation proposal
7        shall meet all of the following criteria:
8                (i) the proposal shall be designed based on
9            community needs assessment completed by either a
10            University partner or other qualified entity with
11            significant community input;
12                (ii) the proposal shall be a collaboration
13            among providers across the care and community
14            spectrum, including preventative care, primary
15            care specialty care, hospital services, mental
16            health and substance abuse services, as well as
17            community-based entities that address the social
18            determinants of health;
19                (iii) the proposal shall be specifically
20            designed to improve healthcare outcomes and reduce
21            healthcare disparities, and improve the
22            coordination, effectiveness, and efficiency of
23            care delivery;
24                (iv) the proposal shall have specific
25            measurable metrics related to disparities that
26            will be tracked by the Department and made public

 

 

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1            by the Department;
2                (v) the proposal shall include a commitment to
3            include Business Enterprise Program certified
4            vendors or other entities controlled and managed
5            by minorities or women; and
6                (vi) the proposal shall specifically increase
7            access to primary, preventive, or specialty care.
8            (F) Entities eligible to be funded.
9                (i) Proposals for funding should come from
10            collaborations operating in one of the most
11            distressed communities in Illinois as determined
12            by the U.S. Centers for Disease Control and
13            Prevention's Social Vulnerability Index for
14            Illinois and areas disproportionately impacted by
15            COVID-19 or from rural areas of Illinois.
16                (ii) The Department shall prioritize
17            partnerships from distressed communities, which
18            include Business Enterprise Program certified
19            vendors or other entities controlled and managed
20            by minorities or women and also include one or
21            more of the following: safety-net hospitals,
22            critical access hospitals, the campuses of
23            hospitals that have closed since January 1, 2018,
24            or other healthcare providers designed to address
25            specific healthcare disparities, including the
26            impact of COVID-19 on individuals and the

 

 

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1            community and the need for post-COVID care. All
2            funded proposals must include specific measurable
3            goals and metrics related to improved outcomes and
4            reduced disparities which shall be tracked by the
5            Department.
6                (iii) The Department should target the funding
7            in the following ways: $30,000,000 of
8            transformation funds to projects that are a
9            collaboration between a safety-net hospital,
10            particularly community safety-net hospitals, and
11            other providers and designed to address specific
12            healthcare disparities, $20,000,000 of
13            transformation funds to collaborations between
14            safety-net hospitals and a larger hospital partner
15            that increases specialty care in distressed
16            communities, $30,000,000 of transformation funds
17            to projects that are a collaboration between
18            hospitals and other providers in distressed areas
19            of the State designed to address specific
20            healthcare disparities, $15,000,000 to
21            collaborations between critical access hospitals
22            and other providers designed to address specific
23            healthcare disparities, and $15,000,000 to
24            cross-provider collaborations designed to address
25            specific healthcare disparities, and $5,000,000 to
26            collaborations that focus on workforce

 

 

10200HB4343sam001- 21 -LRB102 22609 KTG 38977 a

1            development.
2                (iv) The Department may allocate up to
3            $5,000,000 for planning, racial equity analysis,
4            or consulting resources for the Department or
5            entities without the resources to develop a plan
6            to meet the criteria of this Section. Any contract
7            for consulting services issued by the Department
8            under this subparagraph shall comply with the
9            provisions of Section 5-45 of the State Officials
10            and Employees Ethics Act. Based on availability of
11            federal funding, the Department may directly
12            procure consulting services or provide funding to
13            the collaboration. The provision of resources
14            under this subparagraph is not a guarantee that a
15            project will be approved.
16                (v) The Department shall take steps to ensure
17            that safety-net hospitals operating in
18            under-resourced communities receive priority
19            access to hospital and healthcare transformation
20            funds, including consulting funds, as provided
21            under this Section.
22            (G) Process for submitting and approving projects
23        for distressed communities. The Department shall issue
24        a template for application. The Department shall post
25        any proposal received on the Department's website for
26        at least 2 weeks for public comment, and any such

 

 

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1        public comment shall also be considered in the review
2        process. Applicants may request that proprietary
3        financial information be redacted from publicly posted
4        proposals and the Department in its discretion may
5        agree. Proposals for each distressed community must
6        include all of the following:
7                (i) A detailed description of how the project
8            intends to affect the goals outlined in this
9            subsection, describing new interventions, new
10            technology, new structures, and other changes to
11            the healthcare delivery system planned.
12                (ii) A detailed description of the racial and
13            ethnic makeup of the entities' board and
14            leadership positions and the salaries of the
15            executive staff of entities in the partnership
16            that is seeking to obtain funding under this
17            Section.
18                (iii) A complete budget, including an overall
19            timeline and a detailed pathway to sustainability
20            within a 5-year period, specifying other sources
21            of funding, such as in-kind, cost-sharing, or
22            private donations, particularly for capital needs.
23            There is an expectation that parties to the
24            transformation project dedicate resources to the
25            extent they are able and that these expectations
26            are delineated separately for each entity in the

 

 

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1            proposal.
2                (iv) A description of any new entities formed
3            or other legal relationships between collaborating
4            entities and how funds will be allocated among
5            participants.
6                (v) A timeline showing the evolution of sites
7            and specific services of the project over a 5-year
8            period, including services available to the
9            community by site.
10                (vi) Clear milestones indicating progress
11            toward the proposed goals of the proposal as
12            checkpoints along the way to continue receiving
13            funding. The Department is authorized to refine
14            these milestones in agreements, and is authorized
15            to impose reasonable penalties, including
16            repayment of funds, for substantial lack of
17            progress.
18                (vii) A clear statement of the level of
19            commitment the project will include for minorities
20            and women in contracting opportunities, including
21            as equity partners where applicable, or as
22            subcontractors and suppliers in all phases of the
23            project.
24                (viii) If the community study utilized is not
25            the study commissioned and published by the
26            Department, the applicant must define the

 

 

10200HB4343sam001- 24 -LRB102 22609 KTG 38977 a

1            methodology used, including documentation of clear
2            community participation.
3                (ix) A description of the process used in
4            collaborating with all levels of government in the
5            community served in the development of the
6            project, including, but not limited to,
7            legislators and officials of other units of local
8            government.
9                (x) Documentation of a community input process
10            in the community served, including links to
11            proposal materials on public websites.
12                (xi) Verifiable project milestones and quality
13            metrics that will be impacted by transformation.
14            These project milestones and quality metrics must
15            be identified with improvement targets that must
16            be met.
17                (xii) Data on the number of existing employees
18            by various job categories and wage levels by the
19            zip code of the employees' residence and
20            benchmarks for the continued maintenance and
21            improvement of these levels. The proposal must
22            also describe any retraining or other workforce
23            development planned for the new project.
24                (xiii) If a new entity is created by the
25            project, a description of how the board will be
26            reflective of the community served by the

 

 

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1            proposal.
2                (xiv) An explanation of how the proposal will
3            address the existing disparities that exacerbated
4            the impact of COVID-19 and the need for post-COVID
5            care in the community, if applicable.
6                (xv) An explanation of how the proposal is
7            designed to increase access to care, including
8            specialty care based upon the community's needs.
9            (H) The Department shall evaluate proposals for
10        compliance with the criteria listed under subparagraph
11        (G). Proposals meeting all of the criteria may be
12        eligible for funding with the areas of focus
13        prioritized as described in item (ii) of subparagraph
14        (F). Based on the funds available, the Department may
15        negotiate funding agreements with approved applicants
16        to maximize federal funding. Nothing in this
17        subsection requires that an approved project be funded
18        to the level requested. Agreements shall specify the
19        amount of funding anticipated annually, the
20        methodology of payments, the limit on the number of
21        years such funding may be provided, and the milestones
22        and quality metrics that must be met by the projects in
23        order to continue to receive funding during each year
24        of the program. Agreements shall specify the terms and
25        conditions under which a health care facility that
26        receives funds under a purchase of care agreement and

 

 

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1        closes in violation of the terms of the agreement must
2        pay an early closure fee no greater than 50% of the
3        funds it received under the agreement, prior to the
4        Health Facilities and Services Review Board
5        considering an application for closure of the
6        facility. Any project that is funded shall be required
7        to provide quarterly written progress reports, in a
8        form prescribed by the Department, and at a minimum
9        shall include the progress made in achieving any
10        milestones or metrics or Business Enterprise Program
11        commitments in its plan. The Department may reduce or
12        end payments, as set forth in transformation plans, if
13        milestones or metrics or Business Enterprise Program
14        commitments are not achieved. The Department shall
15        seek to make payments from the transformation fund in
16        a manner that is eligible for federal matching funds.
17            In reviewing the proposals, the Department shall
18        take into account the needs of the community, data
19        from the study commissioned by the Department from the
20        University of Illinois-Chicago if applicable, feedback
21        from public comment on the Department's website, as
22        well as how the proposal meets the criteria listed
23        under subparagraph (G). Alignment with the
24        Department's overall strategic initiatives shall be an
25        important factor. To the extent that fiscal year
26        funding is not adequate to fund all eligible projects

 

 

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1        that apply, the Department shall prioritize
2        applications that most comprehensively and effectively
3        address the criteria listed under subparagraph (G).
4        (3) (Blank).
5        (4) Hospital Transformation Review Committee. There is
6    created the Hospital Transformation Review Committee. The
7    Committee shall consist of 14 members. No later than 30
8    days after March 12, 2018 (the effective date of Public
9    Act 100-581), the 4 legislative leaders shall each appoint
10    3 members; the Governor shall appoint the Director of
11    Healthcare and Family Services, or his or her designee, as
12    a member; and the Director of Healthcare and Family
13    Services shall appoint one member. Any vacancy shall be
14    filled by the applicable appointing authority within 15
15    calendar days. The members of the Committee shall select a
16    Chair and a Vice-Chair from among its members, provided
17    that the Chair and Vice-Chair cannot be appointed by the
18    same appointing authority and must be from different
19    political parties. The Chair shall have the authority to
20    establish a meeting schedule and convene meetings of the
21    Committee, and the Vice-Chair shall have the authority to
22    convene meetings in the absence of the Chair. The
23    Committee may establish its own rules with respect to
24    meeting schedule, notice of meetings, and the disclosure
25    of documents; however, the Committee shall not have the
26    power to subpoena individuals or documents and any rules

 

 

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1    must be approved by 9 of the 14 members. The Committee
2    shall perform the functions described in this Section and
3    advise and consult with the Director in the administration
4    of this Section. In addition to reviewing and approving
5    the policies, procedures, and rules for the hospital and
6    health care transformation program, the Committee shall
7    consider and make recommendations related to qualifying
8    criteria and payment methodologies related to safety-net
9    hospitals and children's hospitals. Members of the
10    Committee appointed by the legislative leaders shall be
11    subject to the jurisdiction of the Legislative Ethics
12    Commission, not the Executive Ethics Commission, and all
13    requests under the Freedom of Information Act shall be
14    directed to the applicable Freedom of Information officer
15    for the General Assembly. The Department shall provide
16    operational support to the Committee as necessary. The
17    Committee is dissolved on April 1, 2019.
18    (e) Beginning 36 months after initial implementation, the
19Department shall update the reimbursement components in
20subsections (a) and (b), including standardized amounts and
21weighting factors, and at least once every 4 years and no more
22frequently than annually thereafter. The Department shall
23publish these updates on its website no later than 30 calendar
24days prior to their effective date.
25    (f) Continuation of supplemental payments. Any
26supplemental payments authorized under Illinois Administrative

 

 

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1Code 148 effective January 1, 2014 and that continue during
2the period of July 1, 2014 through December 31, 2014 shall
3remain in effect as long as the assessment imposed by Section
45A-2 that is in effect on December 31, 2017 remains in effect.
5    (g) Notwithstanding subsections (a) through (f) of this
6Section and notwithstanding the changes authorized under
7Section 5-5b.1, any updates to the system shall not result in
8any diminishment of the overall effective rates of
9reimbursement as of the implementation date of the new system
10(July 1, 2014). These updates shall not preclude variations in
11any individual component of the system or hospital rate
12variations. Nothing in this Section shall prohibit the
13Department from increasing the rates of reimbursement or
14developing payments to ensure access to hospital services.
15Nothing in this Section shall be construed to guarantee a
16minimum amount of spending in the aggregate or per hospital as
17spending may be impacted by factors, including, but not
18limited to, the number of individuals in the medical
19assistance program and the severity of illness of the
20individuals.
21    (h) The Department shall have the authority to modify by
22rulemaking any changes to the rates or methodologies in this
23Section as required by the federal government to obtain
24federal financial participation for expenditures made under
25this Section.
26    (i) Except for subsections (g) and (h) of this Section,

 

 

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1the Department shall, pursuant to subsection (c) of Section
25-40 of the Illinois Administrative Procedure Act, provide for
3presentation at the June 2014 hearing of the Joint Committee
4on Administrative Rules (JCAR) additional written notice to
5JCAR of the following rules in order to commence the second
6notice period for the following rules: rules published in the
7Illinois Register, rule dated February 21, 2014 at 38 Ill.
8Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
9Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
10Related Grouping (DRG) Prospective Payment System (PPS)), and
114977 (Hospital Reimbursement Changes), and published in the
12Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
13(Specialized Health Care Delivery Systems) and 6505 (Hospital
14Services).
15    (j) Out-of-state hospitals. Beginning July 1, 2018, for
16purposes of determining for State fiscal years 2019 and 2020
17and subsequent fiscal years the hospitals eligible for the
18payments authorized under subsections (a) and (b) of this
19Section, the Department shall include out-of-state hospitals
20that are designated a Level I pediatric trauma center or a
21Level I trauma center by the Department of Public Health as of
22December 1, 2017.
23    (k) The Department shall notify each hospital and managed
24care organization, in writing, of the impact of the updates
25under this Section at least 30 calendar days prior to their
26effective date.

 

 

10200HB4343sam001- 31 -LRB102 22609 KTG 38977 a

1(Source: P.A. 101-81, eff. 7-12-19; 101-650, eff. 7-7-20;
2101-655, eff. 3-12-21; 102-682, eff. 12-10-21.)
 
3
ARTICLE 10.

 
4    Section 10-5. The Illinois Public Aid Code is amended by
5changing Section 5-18.5 as follows:
 
6    (305 ILCS 5/5-18.5)
7    Sec. 5-18.5. Perinatal doula and evidence-based home
8visiting services.
9    (a) As used in this Section:
10    "Home visiting" means a voluntary, evidence-based strategy
11used to support pregnant people, infants, and young children
12and their caregivers to promote infant, child, and maternal
13health, to foster educational development and school
14readiness, and to help prevent child abuse and neglect. Home
15visitors are trained professionals whose visits and activities
16focus on promoting strong parent-child attachment to foster
17healthy child development.
18    "Perinatal doula" means a trained provider who provides
19regular, voluntary physical, emotional, and educational
20support, but not medical or midwife care, to pregnant and
21birthing persons before, during, and after childbirth,
22otherwise known as the perinatal period.
23    "Perinatal doula training" means any doula training that

 

 

10200HB4343sam001- 32 -LRB102 22609 KTG 38977 a

1focuses on providing support throughout the prenatal, labor
2and delivery, or postpartum period, and reflects the type of
3doula care that the doula seeks to provide.
4    (b) Notwithstanding any other provision of this Article,
5perinatal doula services and evidence-based home visiting
6services shall be covered under the medical assistance
7program, subject to appropriation, for persons who are
8otherwise eligible for medical assistance under this Article.
9Perinatal doula services include regular visits beginning in
10the prenatal period and continuing into the postnatal period,
11inclusive of continuous support during labor and delivery,
12that support healthy pregnancies and positive birth outcomes.
13Perinatal doula services may be embedded in an existing
14program, such as evidence-based home visiting. Perinatal doula
15services provided during the prenatal period may be provided
16weekly, services provided during the labor and delivery period
17may be provided for the entire duration of labor and the time
18immediately following birth, and services provided during the
19postpartum period may be provided up to 12 months postpartum.
20    (b-5) Notwithstanding any other provision of this Article,
21beginning January 1, 2023, licensed certified professional
22midwife services shall be covered under the medical assistance
23program, subject to appropriation, for persons who are
24otherwise eligible for medical assistance under this Article.
25The Department shall consult with midwives on reimbursement
26rates for midwifery services.

 

 

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1    (c) The Department of Healthcare and Family Services shall
2adopt rules to administer this Section. In this rulemaking,
3the Department shall consider the expertise of and consult
4with doula program experts, doula training providers,
5practicing doulas, and home visiting experts, along with State
6agencies implementing perinatal doula services and relevant
7bodies under the Illinois Early Learning Council. This body of
8experts shall inform the Department on the credentials
9necessary for perinatal doula and home visiting services to be
10eligible for Medicaid reimbursement and the rate of
11reimbursement for home visiting and perinatal doula services
12in the prenatal, labor and delivery, and postpartum periods.
13Every 2 years, the Department shall assess the rates of
14reimbursement for perinatal doula and home visiting services
15and adjust rates accordingly.
16    (d) The Department shall seek such State plan amendments
17or waivers as may be necessary to implement this Section and
18shall secure federal financial participation for expenditures
19made by the Department in accordance with this Section.
20(Source: P.A. 102-4, eff. 4-27-21.)
 
21
ARTICLE 15.

 
22    Section 15-5. The Illinois Public Aid Code is amended by
23changing Section 5-4 as follows:
 

 

 

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1    (305 ILCS 5/5-4)  (from Ch. 23, par. 5-4)
2    Sec. 5-4. Amount and nature of medical assistance.
3    (a) The amount and nature of medical assistance shall be
4determined in accordance with the standards, rules, and
5regulations of the Department of Healthcare and Family
6Services, with due regard to the requirements and conditions
7in each case, including contributions available from legally
8responsible relatives. However, the amount and nature of such
9medical assistance shall not be affected by the payment of any
10grant under the Senior Citizens and Persons with Disabilities
11Property Tax Relief Act or any distributions or items of
12income described under subparagraph (X) of paragraph (2) of
13subsection (a) of Section 203 of the Illinois Income Tax Act.
14The amount and nature of medical assistance shall not be
15affected by the receipt of donations or benefits from
16fundraisers in cases of serious illness, as long as neither
17the person nor members of the person's family have actual
18control over the donations or benefits or the disbursement of
19the donations or benefits.
20    In determining the income and resources available to the
21institutionalized spouse and to the community spouse, the
22Department of Healthcare and Family Services shall follow the
23procedures established by federal law. If an institutionalized
24spouse or community spouse refuses to comply with the
25requirements of Title XIX of the federal Social Security Act
26and the regulations duly promulgated thereunder by failing to

 

 

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1provide the total value of assets, including income and
2resources, to the extent either the institutionalized spouse
3or community spouse has an ownership interest in them pursuant
4to 42 U.S.C. 1396r-5, such refusal may result in the
5institutionalized spouse being denied eligibility and
6continuing to remain ineligible for the medical assistance
7program based on failure to cooperate.
8    Subject to federal approval, beginning January 1, 2023,
9the community spouse resource allowance shall be established
10and maintained as follows: a base amount of $109,560 plus an
11additional amount of $2,784 added to the base amount each year
12for a period of 10 years commencing with calendar year 2024
13through calendar year 2034. In addition to the base amount and
14the additional amount shall be any increase each year from the
15prior year to the maximum resource allowance permitted under
16Section 1924(f)(2)(A)(ii)(II) of the Social Security Act.
17Subject to federal approval, beginning January 1, 2034 the
18community spouse resource allowance shall be established and
19maintained at the maximum amount permitted under Section
201924(f)(2)(A)(ii)(II) of the Social Security Act, as now or
21hereafter amended, or an amount set after a fair hearing.
22Subject to federal approval, beginning January 1, 2023 the the
23community spouse resource allowance shall be established and
24maintained at the higher of $109,560 or the minimum level
25permitted pursuant to Section 1924(f)(2) of the Social
26Security Act, as now or hereafter amended, or an amount set

 

 

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1after a fair hearing, whichever is greater. The monthly
2maintenance allowance for the community spouse shall be
3established and maintained at the maximum amount higher of
4$2,739 per month or the minimum level permitted pursuant to
5Section 1924(d)(3)(C) of the Social Security Act, as now or
6hereafter amended, or an amount set after a fair hearing,
7whichever is greater. Subject to the approval of the Secretary
8of the United States Department of Health and Human Services,
9the provisions of this Section shall be extended to persons
10who but for the provision of home or community-based services
11under Section 4.02 of the Illinois Act on the Aging, would
12require the level of care provided in an institution, as is
13provided for in federal law.
14    (b) Spousal support for institutionalized spouses
15receiving medical assistance.
16        (i) The Department may seek support for an
17    institutionalized spouse, who has assigned his or her
18    right of support from his or her spouse to the State, from
19    the resources and income available to the community
20    spouse.
21        (ii) The Department may bring an action in the circuit
22    court to establish support orders or itself establish
23    administrative support orders by any means and procedures
24    authorized in this Code, as applicable, except that the
25    standard and regulations for determining ability to
26    support in Section 10-3 shall not limit the amount of

 

 

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1    support that may be ordered.
2        (iii) Proceedings may be initiated to obtain support,
3    or for the recovery of aid granted during the period such
4    support was not provided, or both, for the obtainment of
5    support and the recovery of the aid provided. Proceedings
6    for the recovery of aid may be taken separately or they may
7    be consolidated with actions to obtain support. Such
8    proceedings may be brought in the name of the person or
9    persons requiring support or may be brought in the name of
10    the Department, as the case requires.
11        (iv) The orders for the payment of moneys for the
12    support of the person shall be just and equitable and may
13    direct payment thereof for such period or periods of time
14    as the circumstances require, including support for a
15    period before the date the order for support is entered.
16    In no event shall the orders reduce the community spouse
17    resource allowance below the level established in
18    subsection (a) of this Section or an amount set after a
19    fair hearing, whichever is greater, or reduce the monthly
20    maintenance allowance for the community spouse below the
21    level permitted pursuant to subsection (a) of this
22    Section.
23(Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)
 
24
ARTICLE 20.

 

 

 

10200HB4343sam001- 38 -LRB102 22609 KTG 38977 a

1    Section 20-5. The Illinois Public Aid Code is amended by
2adding Sections 5-5.05d, 5-5.05e, 5-5.05f, 5-5.05g, 5-5.06c,
3and 5-5.06d as follows:
 
4    (305 ILCS 5/5-5.05d new)
5    Sec. 5-5.05d. Academic detailing for behavioral health
6providers. The Department shall develop, in collaboration with
7associations representing behavioral health providers, a
8program designed to provide behavioral health providers and
9providers in academic medical settings who need assistance in
10caring for patients with severe mental illness or a
11developmental disability under the medical assistance program
12with academic detailing and clinical consultation over the
13phone from a qualified provider on how to best care for the
14patient. The Department shall include the phone number on its
15website and notify providers that the service is available.
16The Department may create an in-person option if adequate
17staff is available. To the extent practicable, the Department
18shall build upon this service to address worker shortages and
19the availability of specialty services.
 
20    (305 ILCS 5/5-5.05e new)
21    Sec. 5-5.05e. Tracking availability of beds for withdrawal
22management services. The Department of Human Services shall
23track, or contract with an organization to track, the
24availability of beds for withdrawal management services that

 

 

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1are licensed by the Department and are available to medical
2assistance beneficiaries. The Department of Human Services
3shall update the tracking daily and publish the availability
4of beds online or in another public format.
 
5    (305 ILCS 5/5-5.05f new)
6    Sec. 5-5.05f. Medicaid coverage for peer recovery support
7services. On or before January 1, 2023, the Department shall
8seek approval from the federal Centers for Medicare and
9Medicaid Services to cover peer recovery support services
10under the medical assistance program when rendered by
11certified peer support specialists for the purposes of
12supporting the recovery of individuals receiving substance use
13disorder treatment. As used in this Section, "certified peer
14support specialist" means an individual who:
15        (1) is a self-identified current or former recipient
16    of substance use disorder services who has the ability to
17    support other individuals diagnosed with a substance use
18    disorder;
19        (2) is affiliated with a substance use prevention and
20    recovery provider agency that is licensed by the
21    Department of Human Services' Division of Substance Use
22    Prevention and Recovery; and
23            (A) is certified in accordance with applicable
24        State law to provide peer recovery support services in
25        substance use disorder settings; or

 

 

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1            (B) is certified as qualified to furnish peer
2        support services under a certification process
3        consistent with the National Practice Guidelines for
4        Peer Supporters and inclusive of the core competencies
5        identified by the Substance Abuse and Mental Health
6        Services Administration in the Core Competencies for
7        Peer Workers in Behavioral Health Services.
 
8    (305 ILCS 5/5-5.05g new)
9    Sec. 5-5.05g. Alignment of substance use prevention and
10recovery and mental health policy. The Department and the
11Department of Human Services shall collaborate to review
12coverage and billing requirements for substance use prevention
13and recovery and mental health services with the goal of
14identifying disparities and streamlining coverage and billing
15requirements to reduce the administrative burden for providers
16and medical assistance beneficiaries.
 
17    (305 ILCS 5/5-5.06c new)
18    Sec. 5-5.06c. Access to prenatal and postpartum care. To
19ensure access to high quality prenatal and postpartum care and
20to promote continuity of care for pregnant individuals, the
21Department shall increase the rate for prenatal and postpartum
22visits to no less than the rate for an adult well visit,
23including any applicable add-ons, beginning on January 1,
242023. Bundled rates that include prenatal or postpartum visits

 

 

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1shall incorporate this increased rate, beginning on January 1,
22023.
 
3    (305 ILCS 5/5-5.06d new)
4    Sec. 5-5.06d. External cephalic version rate. To encourage
5provider use of external cephalic versions and decrease the
6rates of caesarean sections in Illinois, the Department shall
7evaluate the rate for external cephalic versions and increase
8the rate by an amount determined by the Department to promote
9safer birthing options for pregnant individuals, beginning on
10January 1, 2023.
 
11
ARTICLE 25.

 
12    Section 25-5. The Illinois Public Aid Code is amended by
13adding Section 5-5.06e as follows:
 
14    (305 ILCS 5/5-5.06e new)
15    Sec. 5-5.06e. Increased funding for dental services.
16Beginning January 1, 2023, the amount allocated to fund rates
17for dental services provided to adults and children under the
18medical assistance program shall be increased by an
19approximate amount of $10,000,000.
 
20
ARTICLE 30.

 

 

 

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1    Section 30-5. The Illinois Public Aid Code is amended by
2changing Section 5-5 as follows:
 
3    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
4    Sec. 5-5. Medical services. The Illinois Department, by
5rule, shall determine the quantity and quality of and the rate
6of reimbursement for the medical assistance for which payment
7will be authorized, and the medical services to be provided,
8which may include all or part of the following: (1) inpatient
9hospital services; (2) outpatient hospital services; (3) other
10laboratory and X-ray services; (4) skilled nursing home
11services; (5) physicians' services whether furnished in the
12office, the patient's home, a hospital, a skilled nursing
13home, or elsewhere; (6) medical care, or any other type of
14remedial care furnished by licensed practitioners; (7) home
15health care services; (8) private duty nursing service; (9)
16clinic services; (10) dental services, including prevention
17and treatment of periodontal disease and dental caries disease
18for pregnant individuals, provided by an individual licensed
19to practice dentistry or dental surgery; for purposes of this
20item (10), "dental services" means diagnostic, preventive, or
21corrective procedures provided by or under the supervision of
22a dentist in the practice of his or her profession; (11)
23physical therapy and related services; (12) prescribed drugs,
24dentures, and prosthetic devices; and eyeglasses prescribed by
25a physician skilled in the diseases of the eye, or by an

 

 

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1optometrist, whichever the person may select; (13) other
2diagnostic, screening, preventive, and rehabilitative
3services, including to ensure that the individual's need for
4intervention or treatment of mental disorders or substance use
5disorders or co-occurring mental health and substance use
6disorders is determined using a uniform screening, assessment,
7and evaluation process inclusive of criteria, for children and
8adults; for purposes of this item (13), a uniform screening,
9assessment, and evaluation process refers to a process that
10includes an appropriate evaluation and, as warranted, a
11referral; "uniform" does not mean the use of a singular
12instrument, tool, or process that all must utilize; (14)
13transportation and such other expenses as may be necessary;
14(15) medical treatment of sexual assault survivors, as defined
15in Section 1a of the Sexual Assault Survivors Emergency
16Treatment Act, for injuries sustained as a result of the
17sexual assault, including examinations and laboratory tests to
18discover evidence which may be used in criminal proceedings
19arising from the sexual assault; (16) the diagnosis and
20treatment of sickle cell anemia; (16.5) services performed by
21a chiropractic physician licensed under the Medical Practice
22Act of 1987 and acting within the scope of his or her license,
23including, but not limited to, chiropractic manipulative
24treatment; and (17) any other medical care, and any other type
25of remedial care recognized under the laws of this State. The
26term "any other type of remedial care" shall include nursing

 

 

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1care and nursing home service for persons who rely on
2treatment by spiritual means alone through prayer for healing.
3    Notwithstanding any other provision of this Section, a
4comprehensive tobacco use cessation program that includes
5purchasing prescription drugs or prescription medical devices
6approved by the Food and Drug Administration shall be covered
7under the medical assistance program under this Article for
8persons who are otherwise eligible for assistance under this
9Article.
10    Notwithstanding any other provision of this Code,
11reproductive health care that is otherwise legal in Illinois
12shall be covered under the medical assistance program for
13persons who are otherwise eligible for medical assistance
14under this Article.
15    Notwithstanding any other provision of this Section, all
16tobacco cessation medications approved by the United States
17Food and Drug Administration and all individual and group
18tobacco cessation counseling services and telephone-based
19counseling services and tobacco cessation medications provided
20through the Illinois Tobacco Quitline shall be covered under
21the medical assistance program for persons who are otherwise
22eligible for assistance under this Article. The Department
23shall comply with all federal requirements necessary to obtain
24federal financial participation, as specified in 42 CFR
25433.15(b)(7), for telephone-based counseling services provided
26through the Illinois Tobacco Quitline, including, but not

 

 

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1limited to: (i) entering into a memorandum of understanding or
2interagency agreement with the Department of Public Health, as
3administrator of the Illinois Tobacco Quitline; and (ii)
4developing a cost allocation plan for Medicaid-allowable
5Illinois Tobacco Quitline services in accordance with 45 CFR
695.507. The Department shall submit the memorandum of
7understanding or interagency agreement, the cost allocation
8plan, and all other necessary documentation to the Centers for
9Medicare and Medicaid Services for review and approval.
10Coverage under this paragraph shall be contingent upon federal
11approval.
12    Notwithstanding any other provision of this Code, the
13Illinois Department may not require, as a condition of payment
14for any laboratory test authorized under this Article, that a
15physician's handwritten signature appear on the laboratory
16test order form. The Illinois Department may, however, impose
17other appropriate requirements regarding laboratory test order
18documentation.
19    Upon receipt of federal approval of an amendment to the
20Illinois Title XIX State Plan for this purpose, the Department
21shall authorize the Chicago Public Schools (CPS) to procure a
22vendor or vendors to manufacture eyeglasses for individuals
23enrolled in a school within the CPS system. CPS shall ensure
24that its vendor or vendors are enrolled as providers in the
25medical assistance program and in any capitated Medicaid
26managed care entity (MCE) serving individuals enrolled in a

 

 

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1school within the CPS system. Under any contract procured
2under this provision, the vendor or vendors must serve only
3individuals enrolled in a school within the CPS system. Claims
4for services provided by CPS's vendor or vendors to recipients
5of benefits in the medical assistance program under this Code,
6the Children's Health Insurance Program, or the Covering ALL
7KIDS Health Insurance Program shall be submitted to the
8Department or the MCE in which the individual is enrolled for
9payment and shall be reimbursed at the Department's or the
10MCE's established rates or rate methodologies for eyeglasses.
11    On and after July 1, 2012, the Department of Healthcare
12and Family Services may provide the following services to
13persons eligible for assistance under this Article who are
14participating in education, training or employment programs
15operated by the Department of Human Services as successor to
16the Department of Public Aid:
17        (1) dental services provided by or under the
18    supervision of a dentist; and
19        (2) eyeglasses prescribed by a physician skilled in
20    the diseases of the eye, or by an optometrist, whichever
21    the person may select.
22    On and after July 1, 2018, the Department of Healthcare
23and Family Services shall provide dental services to any adult
24who is otherwise eligible for assistance under the medical
25assistance program. As used in this paragraph, "dental
26services" means diagnostic, preventative, restorative, or

 

 

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1corrective procedures, including procedures and services for
2the prevention and treatment of periodontal disease and dental
3caries disease, provided by an individual who is licensed to
4practice dentistry or dental surgery or who is under the
5supervision of a dentist in the practice of his or her
6profession.
7    On and after July 1, 2018, targeted dental services, as
8set forth in Exhibit D of the Consent Decree entered by the
9United States District Court for the Northern District of
10Illinois, Eastern Division, in the matter of Memisovski v.
11Maram, Case No. 92 C 1982, that are provided to adults under
12the medical assistance program shall be established at no less
13than the rates set forth in the "New Rate" column in Exhibit D
14of the Consent Decree for targeted dental services that are
15provided to persons under the age of 18 under the medical
16assistance program.
17    Notwithstanding any other provision of this Code and
18subject to federal approval, the Department may adopt rules to
19allow a dentist who is volunteering his or her service at no
20cost to render dental services through an enrolled
21not-for-profit health clinic without the dentist personally
22enrolling as a participating provider in the medical
23assistance program. A not-for-profit health clinic shall
24include a public health clinic or Federally Qualified Health
25Center or other enrolled provider, as determined by the
26Department, through which dental services covered under this

 

 

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1Section are performed. The Department shall establish a
2process for payment of claims for reimbursement for covered
3dental services rendered under this provision.
4    On and after January 1, 2022, the Department of Healthcare
5and Family Services shall administer and regulate a
6school-based dental program that allows for the out-of-office
7delivery of preventative dental services in a school setting
8to children under 19 years of age. The Department shall
9establish, by rule, guidelines for participation by providers
10and set requirements for follow-up referral care based on the
11requirements established in the Dental Office Reference Manual
12published by the Department that establishes the requirements
13for dentists participating in the All Kids Dental School
14Program. Every effort shall be made by the Department when
15developing the program requirements to consider the different
16geographic differences of both urban and rural areas of the
17State for initial treatment and necessary follow-up care. No
18provider shall be charged a fee by any unit of local government
19to participate in the school-based dental program administered
20by the Department. Nothing in this paragraph shall be
21construed to limit or preempt a home rule unit's or school
22district's authority to establish, change, or administer a
23school-based dental program in addition to, or independent of,
24the school-based dental program administered by the
25Department.
26    The Illinois Department, by rule, may distinguish and

 

 

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1classify the medical services to be provided only in
2accordance with the classes of persons designated in Section
35-2.
4    The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11    The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for
14individuals 35 years of age or older who are eligible for
15medical assistance under this Article, as follows:
16        (A) A baseline mammogram for individuals 35 to 39
17    years of age.
18        (B) An annual mammogram for individuals 40 years of
19    age or older.
20        (C) A mammogram at the age and intervals considered
21    medically necessary by the individual's health care
22    provider for individuals under 40 years of age and having
23    a family history of breast cancer, prior personal history
24    of breast cancer, positive genetic testing, or other risk
25    factors.
26        (D) A comprehensive ultrasound screening and MRI of an

 

 

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1    entire breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue or when medically
3    necessary as determined by a physician licensed to
4    practice medicine in all of its branches.
5        (E) A screening MRI when medically necessary, as
6    determined by a physician licensed to practice medicine in
7    all of its branches.
8        (F) A diagnostic mammogram when medically necessary,
9    as determined by a physician licensed to practice medicine
10    in all its branches, advanced practice registered nurse,
11    or physician assistant.
12    The Department shall not impose a deductible, coinsurance,
13copayment, or any other cost-sharing requirement on the
14coverage provided under this paragraph; except that this
15sentence does not apply to coverage of diagnostic mammograms
16to the extent such coverage would disqualify a high-deductible
17health plan from eligibility for a health savings account
18pursuant to Section 223 of the Internal Revenue Code (26
19U.S.C. 223).
20    All screenings shall include a physical breast exam,
21instruction on self-examination and information regarding the
22frequency of self-examination and its value as a preventative
23tool.
24     For purposes of this Section:
25    "Diagnostic mammogram" means a mammogram obtained using
26diagnostic mammography.

 

 

10200HB4343sam001- 51 -LRB102 22609 KTG 38977 a

1    "Diagnostic mammography" means a method of screening that
2is designed to evaluate an abnormality in a breast, including
3an abnormality seen or suspected on a screening mammogram or a
4subjective or objective abnormality otherwise detected in the
5breast.
6    "Low-dose mammography" means the x-ray examination of the
7breast using equipment dedicated specifically for mammography,
8including the x-ray tube, filter, compression device, and
9image receptor, with an average radiation exposure delivery of
10less than one rad per breast for 2 views of an average size
11breast. The term also includes digital mammography and
12includes breast tomosynthesis.
13    "Breast tomosynthesis" means a radiologic procedure that
14involves the acquisition of projection images over the
15stationary breast to produce cross-sectional digital
16three-dimensional images of the breast.
17    If, at any time, the Secretary of the United States
18Department of Health and Human Services, or its successor
19agency, promulgates rules or regulations to be published in
20the Federal Register or publishes a comment in the Federal
21Register or issues an opinion, guidance, or other action that
22would require the State, pursuant to any provision of the
23Patient Protection and Affordable Care Act (Public Law
24111-148), including, but not limited to, 42 U.S.C.
2518031(d)(3)(B) or any successor provision, to defray the cost
26of any coverage for breast tomosynthesis outlined in this

 

 

10200HB4343sam001- 52 -LRB102 22609 KTG 38977 a

1paragraph, then the requirement that an insurer cover breast
2tomosynthesis is inoperative other than any such coverage
3authorized under Section 1902 of the Social Security Act, 42
4U.S.C. 1396a, and the State shall not assume any obligation
5for the cost of coverage for breast tomosynthesis set forth in
6this paragraph.
7    On and after January 1, 2016, the Department shall ensure
8that all networks of care for adult clients of the Department
9include access to at least one breast imaging Center of
10Imaging Excellence as certified by the American College of
11Radiology.
12    On and after January 1, 2012, providers participating in a
13quality improvement program approved by the Department shall
14be reimbursed for screening and diagnostic mammography at the
15same rate as the Medicare program's rates, including the
16increased reimbursement for digital mammography.
17    The Department shall convene an expert panel including
18representatives of hospitals, free-standing mammography
19facilities, and doctors, including radiologists, to establish
20quality standards for mammography.
21    On and after January 1, 2017, providers participating in a
22breast cancer treatment quality improvement program approved
23by the Department shall be reimbursed for breast cancer
24treatment at a rate that is no lower than 95% of the Medicare
25program's rates for the data elements included in the breast
26cancer treatment quality program.

 

 

10200HB4343sam001- 53 -LRB102 22609 KTG 38977 a

1    The Department shall convene an expert panel, including
2representatives of hospitals, free-standing breast cancer
3treatment centers, breast cancer quality organizations, and
4doctors, including breast surgeons, reconstructive breast
5surgeons, oncologists, and primary care providers to establish
6quality standards for breast cancer treatment.
7    Subject to federal approval, the Department shall
8establish a rate methodology for mammography at federally
9qualified health centers and other encounter-rate clinics.
10These clinics or centers may also collaborate with other
11hospital-based mammography facilities. By January 1, 2016, the
12Department shall report to the General Assembly on the status
13of the provision set forth in this paragraph.
14    The Department shall establish a methodology to remind
15individuals who are age-appropriate for screening mammography,
16but who have not received a mammogram within the previous 18
17months, of the importance and benefit of screening
18mammography. The Department shall work with experts in breast
19cancer outreach and patient navigation to optimize these
20reminders and shall establish a methodology for evaluating
21their effectiveness and modifying the methodology based on the
22evaluation.
23    The Department shall establish a performance goal for
24primary care providers with respect to their female patients
25over age 40 receiving an annual mammogram. This performance
26goal shall be used to provide additional reimbursement in the

 

 

10200HB4343sam001- 54 -LRB102 22609 KTG 38977 a

1form of a quality performance bonus to primary care providers
2who meet that goal.
3    The Department shall devise a means of case-managing or
4patient navigation for beneficiaries diagnosed with breast
5cancer. This program shall initially operate as a pilot
6program in areas of the State with the highest incidence of
7mortality related to breast cancer. At least one pilot program
8site shall be in the metropolitan Chicago area and at least one
9site shall be outside the metropolitan Chicago area. On or
10after July 1, 2016, the pilot program shall be expanded to
11include one site in western Illinois, one site in southern
12Illinois, one site in central Illinois, and 4 sites within
13metropolitan Chicago. An evaluation of the pilot program shall
14be carried out measuring health outcomes and cost of care for
15those served by the pilot program compared to similarly
16situated patients who are not served by the pilot program.
17    The Department shall require all networks of care to
18develop a means either internally or by contract with experts
19in navigation and community outreach to navigate cancer
20patients to comprehensive care in a timely fashion. The
21Department shall require all networks of care to include
22access for patients diagnosed with cancer to at least one
23academic commission on cancer-accredited cancer program as an
24in-network covered benefit.
25    On or after July 1, 2022, individuals who are otherwise
26eligible for medical assistance under this Article shall

 

 

10200HB4343sam001- 55 -LRB102 22609 KTG 38977 a

1receive coverage for perinatal depression screenings for the
212-month period beginning on the last day of their pregnancy.
3Medical assistance coverage under this paragraph shall be
4conditioned on the use of a screening instrument approved by
5the Department.
6    Any medical or health care provider shall immediately
7recommend, to any pregnant individual who is being provided
8prenatal services and is suspected of having a substance use
9disorder as defined in the Substance Use Disorder Act,
10referral to a local substance use disorder treatment program
11licensed by the Department of Human Services or to a licensed
12hospital which provides substance abuse treatment services.
13The Department of Healthcare and Family Services shall assure
14coverage for the cost of treatment of the drug abuse or
15addiction for pregnant recipients in accordance with the
16Illinois Medicaid Program in conjunction with the Department
17of Human Services.
18    All medical providers providing medical assistance to
19pregnant individuals under this Code shall receive information
20from the Department on the availability of services under any
21program providing case management services for addicted
22individuals, including information on appropriate referrals
23for other social services that may be needed by addicted
24individuals in addition to treatment for addiction.
25    The Illinois Department, in cooperation with the
26Departments of Human Services (as successor to the Department

 

 

10200HB4343sam001- 56 -LRB102 22609 KTG 38977 a

1of Alcoholism and Substance Abuse) and Public Health, through
2a public awareness campaign, may provide information
3concerning treatment for alcoholism and drug abuse and
4addiction, prenatal health care, and other pertinent programs
5directed at reducing the number of drug-affected infants born
6to recipients of medical assistance.
7    Neither the Department of Healthcare and Family Services
8nor the Department of Human Services shall sanction the
9recipient solely on the basis of the recipient's substance
10abuse.
11    The Illinois Department shall establish such regulations
12governing the dispensing of health services under this Article
13as it shall deem appropriate. The Department should seek the
14advice of formal professional advisory committees appointed by
15the Director of the Illinois Department for the purpose of
16providing regular advice on policy and administrative matters,
17information dissemination and educational activities for
18medical and health care providers, and consistency in
19procedures to the Illinois Department.
20    The Illinois Department may develop and contract with
21Partnerships of medical providers to arrange medical services
22for persons eligible under Section 5-2 of this Code.
23Implementation of this Section may be by demonstration
24projects in certain geographic areas. The Partnership shall be
25represented by a sponsor organization. The Department, by
26rule, shall develop qualifications for sponsors of

 

 

10200HB4343sam001- 57 -LRB102 22609 KTG 38977 a

1Partnerships. Nothing in this Section shall be construed to
2require that the sponsor organization be a medical
3organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and
13the Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by
17    the Partnership may receive an additional surcharge for
18    such services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

10200HB4343sam001- 58 -LRB102 22609 KTG 38977 a

1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that
14provided services may be accessed from therapeutically
15certified optometrists to the full extent of the Illinois
16Optometric Practice Act of 1987 without discriminating between
17service providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance
24under this Article. Such records must be retained for a period
25of not less than 6 years from the date of service or as
26provided by applicable State law, whichever period is longer,

 

 

10200HB4343sam001- 59 -LRB102 22609 KTG 38977 a

1except that if an audit is initiated within the required
2retention period then the records must be retained until the
3audit is completed and every exception is resolved. The
4Illinois Department shall require health care providers to
5make available, when authorized by the patient, in writing,
6the medical records in a timely fashion to other health care
7providers who are treating or serving persons eligible for
8Medical Assistance under this Article. All dispensers of
9medical services shall be required to maintain and retain
10business and professional records sufficient to fully and
11accurately document the nature, scope, details and receipt of
12the health care provided to persons eligible for medical
13assistance under this Code, in accordance with regulations
14promulgated by the Illinois Department. The rules and
15regulations shall require that proof of the receipt of
16prescription drugs, dentures, prosthetic devices and
17eyeglasses by eligible persons under this Section accompany
18each claim for reimbursement submitted by the dispenser of
19such medical services. No such claims for reimbursement shall
20be approved for payment by the Illinois Department without
21such proof of receipt, unless the Illinois Department shall
22have put into effect and shall be operating a system of
23post-payment audit and review which shall, on a sampling
24basis, be deemed adequate by the Illinois Department to assure
25that such drugs, dentures, prosthetic devices and eyeglasses
26for which payment is being made are actually being received by

 

 

10200HB4343sam001- 60 -LRB102 22609 KTG 38977 a

1eligible recipients. Within 90 days after September 16, 1984
2(the effective date of Public Act 83-1439), the Illinois
3Department shall establish a current list of acquisition costs
4for all prosthetic devices and any other items recognized as
5medical equipment and supplies reimbursable under this Article
6and shall update such list on a quarterly basis, except that
7the acquisition costs of all prescription drugs shall be
8updated no less frequently than every 30 days as required by
9Section 5-5.12.
10    Notwithstanding any other law to the contrary, the
11Illinois Department shall, within 365 days after July 22, 2013
12(the effective date of Public Act 98-104), establish
13procedures to permit skilled care facilities licensed under
14the Nursing Home Care Act to submit monthly billing claims for
15reimbursement purposes. Following development of these
16procedures, the Department shall, by July 1, 2016, test the
17viability of the new system and implement any necessary
18operational or structural changes to its information
19technology platforms in order to allow for the direct
20acceptance and payment of nursing home claims.
21    Notwithstanding any other law to the contrary, the
22Illinois Department shall, within 365 days after August 15,
232014 (the effective date of Public Act 98-963), establish
24procedures to permit ID/DD facilities licensed under the ID/DD
25Community Care Act and MC/DD facilities licensed under the
26MC/DD Act to submit monthly billing claims for reimbursement

 

 

10200HB4343sam001- 61 -LRB102 22609 KTG 38977 a

1purposes. Following development of these procedures, the
2Department shall have an additional 365 days to test the
3viability of the new system and to ensure that any necessary
4operational or structural changes to its information
5technology platforms are implemented.
6    The Illinois Department shall require all dispensers of
7medical services, other than an individual practitioner or
8group of practitioners, desiring to participate in the Medical
9Assistance program established under this Article to disclose
10all financial, beneficial, ownership, equity, surety or other
11interests in any and all firms, corporations, partnerships,
12associations, business enterprises, joint ventures, agencies,
13institutions or other legal entities providing any form of
14health care services in this State under this Article.
15    The Illinois Department may require that all dispensers of
16medical services desiring to participate in the medical
17assistance program established under this Article disclose,
18under such terms and conditions as the Illinois Department may
19by rule establish, all inquiries from clients and attorneys
20regarding medical bills paid by the Illinois Department, which
21inquiries could indicate potential existence of claims or
22liens for the Illinois Department.
23    Enrollment of a vendor shall be subject to a provisional
24period and shall be conditional for one year. During the
25period of conditional enrollment, the Department may terminate
26the vendor's eligibility to participate in, or may disenroll

 

 

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1the vendor from, the medical assistance program without cause.
2Unless otherwise specified, such termination of eligibility or
3disenrollment is not subject to the Department's hearing
4process. However, a disenrolled vendor may reapply without
5penalty.
6    The Department has the discretion to limit the conditional
7enrollment period for vendors based upon category of risk of
8the vendor.
9    Prior to enrollment and during the conditional enrollment
10period in the medical assistance program, all vendors shall be
11subject to enhanced oversight, screening, and review based on
12the risk of fraud, waste, and abuse that is posed by the
13category of risk of the vendor. The Illinois Department shall
14establish the procedures for oversight, screening, and review,
15which may include, but need not be limited to: criminal and
16financial background checks; fingerprinting; license,
17certification, and authorization verifications; unscheduled or
18unannounced site visits; database checks; prepayment audit
19reviews; audits; payment caps; payment suspensions; and other
20screening as required by federal or State law.
21    The Department shall define or specify the following: (i)
22by provider notice, the "category of risk of the vendor" for
23each type of vendor, which shall take into account the level of
24screening applicable to a particular category of vendor under
25federal law and regulations; (ii) by rule or provider notice,
26the maximum length of the conditional enrollment period for

 

 

10200HB4343sam001- 63 -LRB102 22609 KTG 38977 a

1each category of risk of the vendor; and (iii) by rule, the
2hearing rights, if any, afforded to a vendor in each category
3of risk of the vendor that is terminated or disenrolled during
4the conditional enrollment period.
5    To be eligible for payment consideration, a vendor's
6payment claim or bill, either as an initial claim or as a
7resubmitted claim following prior rejection, must be received
8by the Illinois Department, or its fiscal intermediary, no
9later than 180 days after the latest date on the claim on which
10medical goods or services were provided, with the following
11exceptions:
12        (1) In the case of a provider whose enrollment is in
13    process by the Illinois Department, the 180-day period
14    shall not begin until the date on the written notice from
15    the Illinois Department that the provider enrollment is
16    complete.
17        (2) In the case of errors attributable to the Illinois
18    Department or any of its claims processing intermediaries
19    which result in an inability to receive, process, or
20    adjudicate a claim, the 180-day period shall not begin
21    until the provider has been notified of the error.
22        (3) In the case of a provider for whom the Illinois
23    Department initiates the monthly billing process.
24        (4) In the case of a provider operated by a unit of
25    local government with a population exceeding 3,000,000
26    when local government funds finance federal participation

 

 

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1    for claims payments.
2    For claims for services rendered during a period for which
3a recipient received retroactive eligibility, claims must be
4filed within 180 days after the Department determines the
5applicant is eligible. For claims for which the Illinois
6Department is not the primary payer, claims must be submitted
7to the Illinois Department within 180 days after the final
8adjudication by the primary payer.
9    In the case of long term care facilities, within 120
10calendar days of receipt by the facility of required
11prescreening information, new admissions with associated
12admission documents shall be submitted through the Medical
13Electronic Data Interchange (MEDI) or the Recipient
14Eligibility Verification (REV) System or shall be submitted
15directly to the Department of Human Services using required
16admission forms. Effective September 1, 2014, admission
17documents, including all prescreening information, must be
18submitted through MEDI or REV. Confirmation numbers assigned
19to an accepted transaction shall be retained by a facility to
20verify timely submittal. Once an admission transaction has
21been completed, all resubmitted claims following prior
22rejection are subject to receipt no later than 180 days after
23the admission transaction has been completed.
24    Claims that are not submitted and received in compliance
25with the foregoing requirements shall not be eligible for
26payment under the medical assistance program, and the State

 

 

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1shall have no liability for payment of those claims.
2    To the extent consistent with applicable information and
3privacy, security, and disclosure laws, State and federal
4agencies and departments shall provide the Illinois Department
5access to confidential and other information and data
6necessary to perform eligibility and payment verifications and
7other Illinois Department functions. This includes, but is not
8limited to: information pertaining to licensure;
9certification; earnings; immigration status; citizenship; wage
10reporting; unearned and earned income; pension income;
11employment; supplemental security income; social security
12numbers; National Provider Identifier (NPI) numbers; the
13National Practitioner Data Bank (NPDB); program and agency
14exclusions; taxpayer identification numbers; tax delinquency;
15corporate information; and death records.
16    The Illinois Department shall enter into agreements with
17State agencies and departments, and is authorized to enter
18into agreements with federal agencies and departments, under
19which such agencies and departments shall share data necessary
20for medical assistance program integrity functions and
21oversight. The Illinois Department shall develop, in
22cooperation with other State departments and agencies, and in
23compliance with applicable federal laws and regulations,
24appropriate and effective methods to share such data. At a
25minimum, and to the extent necessary to provide data sharing,
26the Illinois Department shall enter into agreements with State

 

 

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1agencies and departments, and is authorized to enter into
2agreements with federal agencies and departments, including,
3but not limited to: the Secretary of State; the Department of
4Revenue; the Department of Public Health; the Department of
5Human Services; and the Department of Financial and
6Professional Regulation.
7    Beginning in fiscal year 2013, the Illinois Department
8shall set forth a request for information to identify the
9benefits of a pre-payment, post-adjudication, and post-edit
10claims system with the goals of streamlining claims processing
11and provider reimbursement, reducing the number of pending or
12rejected claims, and helping to ensure a more transparent
13adjudication process through the utilization of: (i) provider
14data verification and provider screening technology; and (ii)
15clinical code editing; and (iii) pre-pay, pre- or
16post-adjudicated predictive modeling with an integrated case
17management system with link analysis. Such a request for
18information shall not be considered as a request for proposal
19or as an obligation on the part of the Illinois Department to
20take any action or acquire any products or services.
21    The Illinois Department shall establish policies,
22procedures, standards and criteria by rule for the
23acquisition, repair and replacement of orthotic and prosthetic
24devices and durable medical equipment. Such rules shall
25provide, but not be limited to, the following services: (1)
26immediate repair or replacement of such devices by recipients;

 

 

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1and (2) rental, lease, purchase or lease-purchase of durable
2medical equipment in a cost-effective manner, taking into
3consideration the recipient's medical prognosis, the extent of
4the recipient's needs, and the requirements and costs for
5maintaining such equipment. Subject to prior approval, such
6rules shall enable a recipient to temporarily acquire and use
7alternative or substitute devices or equipment pending repairs
8or replacements of any device or equipment previously
9authorized for such recipient by the Department.
10Notwithstanding any provision of Section 5-5f to the contrary,
11the Department may, by rule, exempt certain replacement
12wheelchair parts from prior approval and, for wheelchairs,
13wheelchair parts, wheelchair accessories, and related seating
14and positioning items, determine the wholesale price by
15methods other than actual acquisition costs.
16    The Department shall require, by rule, all providers of
17durable medical equipment to be accredited by an accreditation
18organization approved by the federal Centers for Medicare and
19Medicaid Services and recognized by the Department in order to
20bill the Department for providing durable medical equipment to
21recipients. No later than 15 months after the effective date
22of the rule adopted pursuant to this paragraph, all providers
23must meet the accreditation requirement.
24    In order to promote environmental responsibility, meet the
25needs of recipients and enrollees, and achieve significant
26cost savings, the Department, or a managed care organization

 

 

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1under contract with the Department, may provide recipients or
2managed care enrollees who have a prescription or Certificate
3of Medical Necessity access to refurbished durable medical
4equipment under this Section (excluding prosthetic and
5orthotic devices as defined in the Orthotics, Prosthetics, and
6Pedorthics Practice Act and complex rehabilitation technology
7products and associated services) through the State's
8assistive technology program's reutilization program, using
9staff with the Assistive Technology Professional (ATP)
10Certification if the refurbished durable medical equipment:
11(i) is available; (ii) is less expensive, including shipping
12costs, than new durable medical equipment of the same type;
13(iii) is able to withstand at least 3 years of use; (iv) is
14cleaned, disinfected, sterilized, and safe in accordance with
15federal Food and Drug Administration regulations and guidance
16governing the reprocessing of medical devices in health care
17settings; and (v) equally meets the needs of the recipient or
18enrollee. The reutilization program shall confirm that the
19recipient or enrollee is not already in receipt of the same or
20similar equipment from another service provider, and that the
21refurbished durable medical equipment equally meets the needs
22of the recipient or enrollee. Nothing in this paragraph shall
23be construed to limit recipient or enrollee choice to obtain
24new durable medical equipment or place any additional prior
25authorization conditions on enrollees of managed care
26organizations.

 

 

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1    The Department shall execute, relative to the nursing home
2prescreening project, written inter-agency agreements with the
3Department of Human Services and the Department on Aging, to
4effect the following: (i) intake procedures and common
5eligibility criteria for those persons who are receiving
6non-institutional services; and (ii) the establishment and
7development of non-institutional services in areas of the
8State where they are not currently available or are
9undeveloped; and (iii) notwithstanding any other provision of
10law, subject to federal approval, on and after July 1, 2012, an
11increase in the determination of need (DON) scores from 29 to
1237 for applicants for institutional and home and
13community-based long term care; if and only if federal
14approval is not granted, the Department may, in conjunction
15with other affected agencies, implement utilization controls
16or changes in benefit packages to effectuate a similar savings
17amount for this population; and (iv) no later than July 1,
182013, minimum level of care eligibility criteria for
19institutional and home and community-based long term care; and
20(v) no later than October 1, 2013, establish procedures to
21permit long term care providers access to eligibility scores
22for individuals with an admission date who are seeking or
23receiving services from the long term care provider. In order
24to select the minimum level of care eligibility criteria, the
25Governor shall establish a workgroup that includes affected
26agency representatives and stakeholders representing the

 

 

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1institutional and home and community-based long term care
2interests. This Section shall not restrict the Department from
3implementing lower level of care eligibility criteria for
4community-based services in circumstances where federal
5approval has been granted.
6    The Illinois Department shall develop and operate, in
7cooperation with other State Departments and agencies and in
8compliance with applicable federal laws and regulations,
9appropriate and effective systems of health care evaluation
10and programs for monitoring of utilization of health care
11services and facilities, as it affects persons eligible for
12medical assistance under this Code.
13    The Illinois Department shall report annually to the
14General Assembly, no later than the second Friday in April of
151979 and each year thereafter, in regard to:
16        (a) actual statistics and trends in utilization of
17    medical services by public aid recipients;
18        (b) actual statistics and trends in the provision of
19    the various medical services by medical vendors;
20        (c) current rate structures and proposed changes in
21    those rate structures for the various medical vendors; and
22        (d) efforts at utilization review and control by the
23    Illinois Department.
24    The period covered by each report shall be the 3 years
25ending on the June 30 prior to the report. The report shall
26include suggested legislation for consideration by the General

 

 

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1Assembly. The requirement for reporting to the General
2Assembly shall be satisfied by filing copies of the report as
3required by Section 3.1 of the General Assembly Organization
4Act, and filing such additional copies with the State
5Government Report Distribution Center for the General Assembly
6as is required under paragraph (t) of Section 7 of the State
7Library Act.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
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
17of reimbursement for services or other payments in accordance
18with Section 5-5e.
19    Because kidney transplantation can be an appropriate,
20cost-effective alternative to renal dialysis when medically
21necessary and notwithstanding the provisions of Section 1-11
22of this Code, beginning October 1, 2014, the Department shall
23cover kidney transplantation for noncitizens with end-stage
24renal disease who are not eligible for comprehensive medical
25benefits, who meet the residency requirements of Section 5-3
26of this Code, and who would otherwise meet the financial

 

 

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1requirements of the appropriate class of eligible persons
2under Section 5-2 of this Code. To qualify for coverage of
3kidney transplantation, such person must be receiving
4emergency renal dialysis services covered by the Department.
5Providers under this Section shall be prior approved and
6certified by the Department to perform kidney transplantation
7and the services under this Section shall be limited to
8services associated with kidney transplantation.
9    Notwithstanding any other provision of this Code to the
10contrary, on or after July 1, 2015, all FDA approved forms of
11medication assisted treatment prescribed for the treatment of
12alcohol dependence or treatment of opioid dependence shall be
13covered under both fee for service and managed care medical
14assistance programs for persons who are otherwise eligible for
15medical assistance under this Article and shall not be subject
16to any (1) utilization control, other than those established
17under the American Society of Addiction Medicine patient
18placement criteria, (2) prior authorization mandate, or (3)
19lifetime restriction limit mandate.
20    On or after July 1, 2015, opioid antagonists prescribed
21for the treatment of an opioid overdose, including the
22medication product, administration devices, and any pharmacy
23fees or hospital fees related to the dispensing, distribution,
24and administration of the opioid antagonist, shall be covered
25under the medical assistance program for persons who are
26otherwise eligible for medical assistance under this Article.

 

 

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1As used in this Section, "opioid antagonist" means a drug that
2binds to opioid receptors and blocks or inhibits the effect of
3opioids acting on those receptors, including, but not limited
4to, naloxone hydrochloride or any other similarly acting drug
5approved by the U.S. Food and Drug Administration.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a
23dental hygienist, as defined under the Illinois Dental
24Practice Act, working under the general supervision of a
25dentist and employed by a federally qualified health center.
26    Within 90 days after October 8, 2021 (the effective date

 

 

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1of Public Act 102-665) this amendatory Act of the 102nd
2General Assembly, the Department shall seek federal approval
3of a State Plan amendment to expand coverage for family
4planning services that includes presumptive eligibility to
5individuals whose income is at or below 208% of the federal
6poverty level. Coverage under this Section shall be effective
7beginning no later than December 1, 2022.
8    Subject to approval by the federal Centers for Medicare
9and Medicaid Services of a Title XIX State Plan amendment
10electing the Program of All-Inclusive Care for the Elderly
11(PACE) as a State Medicaid option, as provided for by Subtitle
12I (commencing with Section 4801) of Title IV of the Balanced
13Budget Act of 1997 (Public Law 105-33) and Part 460
14(commencing with Section 460.2) of Subchapter E of Title 42 of
15the Code of Federal Regulations, PACE program services shall
16become a covered benefit of the medical assistance program,
17subject to criteria established in accordance with all
18applicable laws.
19    Notwithstanding any other provision of this Code,
20community-based pediatric palliative care from a trained
21interdisciplinary team shall be covered under the medical
22assistance program as provided in Section 15 of the Pediatric
23Palliative Care Act.
24    Notwithstanding any other provision of this Code, within
2512 months after the effective date of this amendatory Act of
26the 102nd General Assembly and subject to federal approval,

 

 

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1acupuncture services performed by an acupuncturist licensed
2under the Acupuncture Practice Act who is acting within the
3scope of his or her license shall be covered under the medical
4assistance program. The Department shall apply for any federal
5waiver or State Plan amendment, if required, to implement this
6paragraph. The Department may adopt any rules, including
7standards and criteria, necessary to implement this paragraph.
8(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
9102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1035, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1155-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
12102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
131-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)
 
14
ARTICLE 35.

 
15    Section 35-5. The Department of Public Health Powers and
16Duties Law of the Civil Administrative Code of Illinois is
17amended by adding Section 2310-434 as follows:
 
18    (20 ILCS 2310/2310-434 new)
19    Sec. 2310-434. Certified Nursing Assistant Intern Program.
20    (a) As used in this Section, "facility" means a facility
21licensed by the Department under the Nursing Home Care Act,
22the MC/DD Act, or the ID/DD Community Care Act or an
23establishment licensed under the Assisted Living and Shared

 

 

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1Housing Act.
2    (b) The Department shall establish or approve a Certified
3Nursing Assistant Intern Program to address the increasing
4need for trained health care workers and provide additional
5pathways for individuals to become certified nursing
6assistants. Upon successful completion of the classroom
7education and on-the-job training requirements of the Program
8required under this Section, an individual may provide, at a
9facility, the patient and resident care services determined
10under the Program and may perform the procedures listed under
11subsection (e).
12    (c) In order to qualify as a certified nursing assistant
13intern, an individual shall successfully complete at least 8
14hours of classroom education on the services and procedures
15determined under the Program and listed under subsection (e).
16The classroom education shall be:
17        (1) taken within the facility where the certified
18    nursing assistant intern will be employed;
19        (2) proctored by either an advanced practice
20    registered nurse or a registered nurse who holds a
21    bachelor's degree in nursing, has a minimum of 3 years of
22    continuous experience in geriatric care, or is certified
23    as a nursing assistant instructor; and
24        (3) satisfied by the successful completion of an
25    approved 8-hour online training course or in-person group
26    training.

 

 

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1    (d) In order to qualify as a certified nursing assistant
2intern, an individual shall successfully complete at least 24
3hours of on-the-job training in the services and procedures
4determined under the Program and listed under subsection (e),
5as follows:
6        (1) The training program instructor shall be either an
7    advanced practice registered nurse or a registered nurse
8    who holds a bachelor's degree in nursing, has a minimum of
9    3 years of continuous experience in geriatric care, or is
10    certified as a nursing assistant instructor.
11        (2) The training program instructor shall ensure that
12    the student meets the competencies determined under the
13    Program and those listed under subsection (e). The
14    instructor shall document the successful completion or
15    failure of the competencies and any remediation that may
16    allow for the successful completion of the competencies.
17        (3) All on-the-job training shall be under the direct
18    observation of either an advanced practice registered
19    nurse or a registered nurse who holds a bachelor's degree
20    in nursing, has a minimum of 3 years of continuous
21    experience in geriatric care, or is certified as a nursing
22    assistant instructor.
23        (4) All on-the-job training shall be conducted at a
24    facility that is licensed by the State of Illinois and
25    that is the facility where the certified nursing assistant
26    intern will be working.

 

 

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1    (e) A certified nursing assistant intern shall receive
2classroom and on-the-job training on how to provide the
3patient or resident care services and procedures, as
4determined under the Program, that are required of a certified
5nursing assistant's performance skills, including, but not
6limited to, all of the following:
7        (1) Successful completion and maintenance of active
8    certification in both first aid and the American Red
9    Cross' courses on cardiopulmonary resuscitation.
10        (2) Infection control and in-service training required
11    at the facility.
12        (3) Washing a resident's hands.
13        (4) Performing oral hygiene on a resident.
14        (5) Shaving a resident with an electric razor.
15        (6) Giving a resident a partial bath.
16        (7) Making a bed that is occupied.
17        (8) Dressing a resident.
18        (9) Transferring a resident to a wheelchair using a
19    gait belt or transfer belt.
20        (10) Ambulating a resident with a gait belt or
21    transfer belt.
22        (11) Feeding a resident.
23        (12) Calculating a resident's intake and output.
24        (13) Placing a resident in a side-lying position.
25        (14) The Heimlich maneuver.
26    (f) A certified nursing assistant intern may not perform

 

 

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1any of the following on a resident:
2        (1) Shaving with a nonelectric razor.
3        (2) Nail care.
4        (3) Perineal care.
5        (4) Transfer using a mechanical lift.
6        (5) Passive range of motion.
7    (g) A certified nursing assistant intern may only provide
8the patient or resident care services and perform the
9procedures that he or she is deemed qualified to perform that
10are listed under subsection (e). A certified nursing assistant
11intern may not provide the procedures excluded under
12subsection (f).
13    (h) The Program is subject to the Health Care Worker
14Background Check Act and the Health Care Worker Background
15Check Code under 77 Ill. Adm. Code 955. Program participants
16and personnel shall be included on the Health Care Worker
17Registry.
18    (i) A Program participant who has completed the training
19required under paragraph (5) of subsection (a) of Section
203-206 of the Nursing Home Care Act, has completed the Program
21from April 21, 2020 through September 18, 2020, and has shown
22competency in all of the performance skills listed under
23subsection (e) may be considered a certified nursing assistant
24intern once the observing advanced practice registered nurse
25or registered nurse educator has confirmed the Program
26participant's competency in all of those performance skills.

 

 

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1    (j) The requirement under subsection (b) of Section
2395.400 of Title 77 of the Illinois Administrative Code that a
3student must pass a BNATP written competency examination
4within 12 months after the completion of the BNATP does not
5apply to a certified nursing assistant intern under this
6Section. However, upon a Program participant's enrollment in a
7certified nursing assistant course, the requirement under
8subsection (b) of Section 395.400 of Title 77 of the Illinois
9Administrative Code that a student pass a BNATP written
10competency examination within 12 months after completion of
11the BNATP program applies.
12    (k) A certified nursing assistant intern shall enroll in a
13certified nursing assistant program within 6 months after
14completing his or her certified nursing assistant intern
15training under the Program. The individual may continue to
16work as a certified nursing assistant intern during his or her
17certified nursing assistant training. If the scope of work for
18a nurse assistant in training pursuant to 77 Ill. Adm. Code
19300.660 is broader in scope than the work permitted to be
20performed by a certified nursing assistant intern, then the
21certified nursing assistant intern enrolled in certified
22nursing assistant training may perform the work allowed under
2377. Ill. Adm. Code 300.660 with written documentation that the
24certified nursing assistant intern has successfully passed the
25competencies necessary to perform such skills. The facility
26shall maintain documentation as to the additional jobs and

 

 

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1duties the certified nursing assistant intern is authorized to
2perform, which shall be made available to the Department upon
3request. The individual shall receive one hour of credit for
4every hour employed as a certified nursing assistant intern or
5as a temporary nurse assistant, not to exceed 30 hours of
6credit, subject to the approval of an accredited certified
7nursing assistant training program.
8    (l) A facility that seeks to train and employ a certified
9nursing assistant intern at the facility must:
10        (1) not have received or applied for a registered
11    nurse waiver under Section 3-303.1 of the Nursing Home
12    Care Act, if applicable;
13        (2) not have been cited for a violation, except a
14    citation for noncompliance with COVID-19 reporting
15    requirements, that has caused severe harm to or the death
16    of a resident within the 2 years prior to employing a
17    certified nursing assistant; for purposes of this
18    paragraph, the revocation of the facility's ability to
19    hire and train a certified nursing assistant intern shall
20    only occur if the underlying federal citation for the
21    revocation remains substantiated following an informal
22    dispute resolution or independent informal dispute
23    resolution;
24        (3) not have been cited for a violation that resulted
25    in a pattern of certified nursing assistants being removed
26    from the Health Care Worker Registry as a result of

 

 

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1    resident abuse, neglect, or exploitation within the 2
2    years prior to employing a certified nursing assistant
3    intern;
4        (4) if the facility is a skilled nursing facility,
5    meet a minimum staffing ratio of 3.8 hours of nursing and
6    personal care time, as those terms are used in subsection
7    (e) of Section 3-202.05 of the Nursing Home Care Act, each
8    day for a resident needing skilled care and 2.5 hours of
9    nursing and personal care time each day for a resident
10    needing intermediate care;
11        (5) not have lost the ability to offer a Nursing
12    Assistant Training and Competency Evaluation Program as a
13    result of an enforcement action;
14        (6) establish a certified nursing assistant intern
15    mentoring program within the facility for the purposes of
16    increasing education and retention, which must include an
17    experienced certified nurse assistant who has at least 3
18    years of active employment and is employed by the
19    facility;
20        (7) not have a monitor or temporary management placed
21    upon the facility by the Department;
22        (8) not have provided the Department with a notice of
23    imminent closure; and
24        (9) not have had a termination action initiated by the
25    federal Centers for Medicare and Medicaid Services or the
26    Department for failing to comply with minimum regulatory

 

 

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1    or licensure requirements.
2    (m) A facility that does not meet the requirements of
3subsection (l) shall cease its new employment training,
4education, or onboarding of any employee under the Program.
5The facility may resume its new employment training,
6education, or onboarding of an employee under the Program once
7the Department determines that the facility is in compliance
8with subsection (l).
9    (n) To study the effectiveness of the Program, the
10Department shall collect data from participating facilities
11and publish a report on the extent to which the Program brought
12individuals into continuing employment as certified nursing
13assistants in long-term care. Data collected from facilities
14shall include, but shall not be limited to, the number of
15certified nursing assistants employed, the number of persons
16who began participation in the Program, the number of persons
17who successfully completed the Program, and the number of
18persons who continue employment in a long-term care service or
19facility. The report shall be published no later than 6 months
20after the Program end date determined under subsection (p). A
21facility participating in the Program shall, twice annually,
22submit data under this subsection in a manner and time
23determined by the Department. Failure to submit data under
24this subsection shall result in suspension of the facility's
25Program.
26    (o) The Department may adopt emergency rules in accordance

 

 

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1with Section 5-45.21 of the Illinois Administrative Procedure
2Act.
3    (p) The Program shall end upon the termination of the
4Secretary of Health and Human Services' public health
5emergency declaration for COVID-19 or 3 years after the date
6that the Program becomes operational, whichever occurs later.
7    (q) This Section is inoperative 18 months after the
8Program end date determined under subsection (p).
 
9    Section 35-10. The Assisted Living and Shared Housing Act
10is amended by adding Section 77 as follows:
 
11    (210 ILCS 9/77 new)
12    Sec. 77. Certified nursing assistant interns.
13    (a) A certified nursing assistant intern shall report to
14an establishment's charge nurse or nursing supervisor and may
15only be assigned duties authorized in Section 2310-434 of the
16Department of Public Health Powers and Duties Law of the Civil
17Administrative Code of Illinois by a supervising nurse.
18    (b) An establishment shall notify its certified and
19licensed staff members, in writing, that a certified nursing
20assistant intern may only provide the services and perform the
21procedures permitted under Section 2310-434 of the Department
22of Public Health Powers and Duties Law of the Civil
23Administrative Code of Illinois. The notification shall detail
24which duties may be delegated to a certified nursing assistant

 

 

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1intern. The establishment shall establish a policy describing
2the authorized duties, supervision, and evaluation of
3certified nursing assistant interns available upon request of
4the Department and any surveyor.
5    (c) If an establishment learns that a certified nursing
6assistant intern is performing work outside the scope of the
7Certified Nursing Assistant Intern Program's training, the
8establishment shall:
9        (1) stop the certified nursing assistant intern from
10    performing the work;
11        (2) inspect the work and correct mistakes, if the work
12    performed was done improperly;
13        (3) assign the work to the appropriate personnel; and
14        (4) ensure that a thorough assessment of any resident
15    involved in the work performed is completed by a
16    registered nurse.
17    (d) An establishment that employs a certified nursing
18assistant intern in violation of this Section shall be subject
19to civil penalties or fines under subsection (a) of Section
20135.
 
21    Section 35-15. The Nursing Home Care Act is amended by
22adding Section 3-613 as follows:
 
23    (210 ILCS 45/3-613 new)
24    Sec. 3-613. Certified nursing assistant interns.

 

 

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1    (a) A certified nursing assistant intern shall report to a
2facility's charge nurse or nursing supervisor and may only be
3assigned duties authorized in Section 2310-434 of the
4Department of Public Health Powers and Duties Law of the Civil
5Administrative Code of Illinois by a supervising nurse.
6    (b) A facility shall notify its certified and licensed
7staff members, in writing, that a certified nursing assistant
8intern may only provide the services and perform the
9procedures permitted under Section 2310-434 of the Department
10of Public Health Powers and Duties Law of the Civil
11Administrative Code of Illinois. The notification shall detail
12which duties may be delegated to a certified nursing assistant
13intern. The facility shall establish a policy describing the
14authorized duties, supervision, and evaluation of certified
15nursing assistant interns available upon request of the
16Department and any surveyor.
17    (c) If a facility learns that a certified nursing
18assistant intern is performing work outside the scope of the
19Certified Nursing Assistant Intern Program's training, the
20facility shall:
21        (1) stop the certified nursing assistant intern from
22    performing the work;
23        (2) inspect the work and correct mistakes, if the work
24    performed was done improperly;
25        (3) assign the work to the appropriate personnel; and
26        (4) ensure that a thorough assessment of any resident

 

 

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1    involved in the work performed is completed by a
2    registered nurse.
3    (d) A facility that employs a certified nursing assistant
4intern in violation of this Section shall be subject to civil
5penalties or fines under Section 3-305.
6    (e) A minimum of 50% of nursing and personal care time
7shall be provided by a certified nursing assistant, but no
8more than 15% of nursing and personal care time may be provided
9by a certified nursing assistant intern.
 
10    Section 35-20. The MC/DD Act is amended by adding Section
113-613 as follows:
 
12    (210 ILCS 46/3-613 new)
13    Sec. 3-613. Certified nursing assistant interns.
14    (a) A certified nursing assistant intern shall report to a
15facility's charge nurse or nursing supervisor and may only be
16assigned duties authorized in Section 2310-434 of the
17Department of Public Health Powers and Duties Law of the Civil
18Administrative Code of Illinois by a supervising nurse.
19    (b) A facility shall notify its certified and licensed
20staff members, in writing, that a certified nursing assistant
21intern may only provide the services and perform the
22procedures permitted under Section 2310-434 of the Department
23of Public Health Powers and Duties Law of the Civil
24Administrative Code of Illinois. The notification shall detail

 

 

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1which duties may be delegated to a certified nursing assistant
2intern. The facility shall establish a policy describing the
3authorized duties, supervision, and evaluation of certified
4nursing assistant interns available upon request of the
5Department and any surveyor.
6    (c) If a facility learns that a certified nursing
7assistant intern is performing work outside the scope of the
8Certified Nursing Assistant Intern Program's training, the
9facility shall:
10        (1) stop the certified nursing assistant intern from
11    performing the work;
12        (2) inspect the work and correct mistakes, if the work
13    performed was done improperly;
14        (3) assign the work to the appropriate personnel; and
15        (4) ensure that a thorough assessment of any resident
16    involved in the work performed is completed by a
17    registered nurse.
18    (d) A facility that employs a certified nursing assistant
19intern in violation of this Section shall be subject to civil
20penalties or fines under Section 3-305.
 
21    Section 35-25. The ID/DD Community Care Act is amended by
22adding Section 3-613 as follows:
 
23    (210 ILCS 47/3-613 new)
24    Sec. 3-613. Certified nursing assistant interns.

 

 

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1    (a) A certified nursing assistant intern shall report to a
2facility's charge nurse or nursing supervisor and may only be
3assigned duties authorized in Section 2310-434 of the
4Department of Public Health Powers and Duties Law of the Civil
5Administrative Code of Illinois by a supervising nurse.
6    (b) A facility shall notify its certified and licensed
7staff members, in writing, that a certified nursing assistant
8intern may only provide the services and perform the
9procedures permitted under Section 2310-434 of the Department
10of Public Health Powers and Duties Law of the Civil
11Administrative Code of Illinois. The notification shall detail
12which duties may be delegated to a certified nursing assistant
13intern. The facility shall establish a policy describing the
14authorized duties, supervision, and evaluation of certified
15nursing assistant interns available upon request of the
16Department and any surveyor.
17    (c) If a facility learns that a certified nursing
18assistant intern is performing work outside the scope of the
19Certified Nursing Assistant Intern Program's training, the
20facility shall:
21        (1) stop the certified nursing assistant intern from
22    performing the work;
23        (2) inspect the work and correct mistakes, if the work
24    performed was done improperly;
25        (3) assign the work to the appropriate personnel; and
26        (4) ensure that a thorough assessment of any resident

 

 

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1    involved in the work performed is completed by a
2    registered nurse.
3    (d) A facility that employs a certified nursing assistant
4intern in violation of this Section shall be subject to civil
5penalties or fines under Section 3-305.
 
6    Section 35-30. The Illinois Public Aid Code is amended by
7adding Section 5-5.01b as follows:
 
8    (305 ILCS 5/5-5.01b new)
9    Sec. 5-5.01b. Certified Nursing Assistant Intern Program.
10    (a) The Department shall establish or approve a Certified
11Nursing Assistant Intern Program to address the increasing
12need for trained health care workers for the supporting living
13facilities program established under Section 5-5.01a. Upon
14successful completion of the classroom education and
15on-the-job training requirements of the Program under this
16Section, an individual may provide, at a facility certified
17under this Act, the patient and resident care services
18determined under the Program and may perform the procedures
19listed under subsection (d).
20    (b) In order to qualify as a certified nursing assistant
21intern, an individual shall successfully complete at least 8
22hours of classroom education on the services and procedures
23listed under subsection (d). The classroom education shall be:
24        (1) taken within the facility where the certified

 

 

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1    nursing assistant intern will be employed;
2        (2) proctored by either an advanced practice
3    registered nurse or a registered nurse who holds a
4    bachelor's degree in nursing, has a minimum of 3 years of
5    continuous experience in geriatric care, or is certified
6    as a nursing assistant instructor; and
7        (3) satisfied by the successful completion of an
8    approved 8-hour online training course or in-person group
9    training.
10    (c) In order to qualify as a certified nursing assistant
11intern, an individual shall successfully complete at least 24
12hours of on-the-job training in the services and procedures
13determined under the Program and listed under subsection (d),
14as follows:
15        (1) The training program instructor shall be either an
16    advanced practice registered nurse or a registered nurse
17    who holds a bachelor's degree in nursing, has a minimum of
18    3 years of continuous experience in geriatric care, or is
19    certified as a nursing assistant instructor.
20        (2) The training program instructor shall ensure that
21    the student meets the competencies determined under the
22    Program and those listed under subsection (d). The
23    instructor shall document the successful completion or
24    failure of the competencies and any remediation that may
25    allow for the successful completion of the competencies.
26        (3) All on-the-job training shall be under the direct

 

 

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1    observation of either an advanced practice registered
2    nurse or a registered nurse who holds a bachelor's degree
3    in nursing, has a minimum of 3 years of continuous
4    experience in geriatric care, or is certified as a nursing
5    assistant instructor.
6        (4) All on-the-job training shall be conducted at a
7    facility that is licensed by the State of Illinois and
8    that is the facility where the certified nursing assistant
9    intern will be working.
10    (d) A certified nursing assistant intern shall receive
11classroom and on-the-job training on how to provide the
12patient or resident care services and procedures, as
13determined under the Program, that are required of a certified
14nursing assistant's performance skills, including, but not
15limited to, all of the following:
16        (1) Successful completion and maintenance of active
17    certification in both first aid and the American Red
18    Cross' courses on cardiopulmonary resuscitation.
19        (2) Infection control and in-service training required
20    at the facility.
21        (3) Washing a resident's hands.
22        (4) Performing oral hygiene on a resident.
23        (5) Shaving a resident with an electric razor.
24        (6) Giving a resident a partial bath.
25        (7) Making a bed that is occupied.
26        (8) Dressing a resident.

 

 

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1        (9) Transferring a resident to a wheelchair using a
2    gait belt or transfer belt.
3        (10) Ambulating a resident with a gait belt or
4    transfer belt.
5        (11) Feeding a resident.
6        (12) Calculating a resident's intake and output.
7        (13) Placing a resident in a side-lying position.
8        (14) The Heimlich maneuver.
9    (e) A certified nursing assistant intern may not perform
10any of the following on a resident:
11        (1) Shaving with a nonelectric razor.
12        (2) Nail care.
13        (3) Perineal care.
14        (4) Transfer using a mechanical lift.
15        (5) Passive range of motion.
16    (f) A certified nursing assistant intern may only provide
17the patient or resident care services and perform the
18procedures that he or she is deemed qualified to perform that
19are listed under subsection (d). A certified nursing assistant
20intern may not provide the procedures excluded under
21subsection (e).
22    (g) A certified nursing assistant intern shall report to a
23facility's charge nurse or nursing supervisor and may only be
24assigned duties authorized in this Section by a supervising
25nurse.
26    (h) A facility shall notify its certified and licensed

 

 

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1staff members, in writing, that a certified nursing assistant
2intern may only provide the services and perform the
3procedures listed under subsection (d). The notification shall
4detail which duties may be delegated to a certified nursing
5assistant intern.
6    (i) If a facility learns that a certified nursing
7assistant intern is performing work outside of the scope of
8the Program's training, the facility shall:
9        (1) stop the certified nursing assistant intern from
10    performing the work;
11        (2) inspect the work and correct mistakes, if the work
12    performed was done improperly;
13        (3) assign the work to the appropriate personnel; and
14        (4) ensure that a thorough assessment of any resident
15    involved in the work performed is completed by a
16    registered nurse.
17    (j) The Program is subject to the Health Care Worker
18Background Check Act and the Health Care Worker Background
19Check Code under 77 Ill. Adm. Code 955. Program participants
20and personnel shall be included on the Health Care Worker
21Registry.
22    (k) A Program participant who has completed the training
23required under paragraph (5) of subsection (a) of Section
243-206 of the Nursing Home Care Act, has completed the Program
25from April 21, 2020 through September 18, 2020, and has shown
26competency in all of the performance skills listed under

 

 

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1subsection (d) shall be considered a certified nursing
2assistant intern.
3    (l) The requirement under subsection (b) of Section
4395.400 of Title 77 of the Illinois Administrative Code that a
5student must pass a BNATP written competency examination
6within 12 months after the completion of the BNATP does not
7apply to a certified nursing assistant intern under this
8Section. However, upon a Program participant's enrollment in a
9certified nursing assistant course, the requirement under
10subsection (b) of Section 395.400 of Title 77 of the Illinois
11Administrative Code that a student pass a BNATP written
12competency examination within 12 months after completion of
13the BNATP program applies.
14    (m) A certified nursing assistant intern shall enroll in a
15certified nursing assistant program within 6 months after
16completing his or her certified nursing assistant intern
17training under the Program. The individual may continue to
18work as a certified nursing assistant intern during his or her
19certified nursing assistant training. If the scope of work for
20a nurse assistant in training pursuant to 77 Ill. Adm. Code
21300.660 is broader in scope than the work permitted to be
22performed by a certified nursing assistant intern, then the
23certified nursing assistant intern enrolled in certified
24nursing assistant training may perform the work allowed under
2577. Ill. Adm. Code 300.660. The individual shall receive one
26hour of credit for every hour employed as a certified nursing

 

 

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1assistant intern or as a temporary nurse assistant, not to
2exceed 30 hours of credit, subject to the approval of an
3accredited certified nursing assistant training program.
4    (n) A facility that seeks to train and employ a certified
5nursing assistant intern at the facility must:
6        (1) not have received a substantiated citation, that
7    the facility has the right to the appeal, for a violation
8    that has caused severe harm to or the death of a resident
9    within the 2 years prior to employing a certified nursing
10    assistant intern; and
11        (2) establish a certified nursing assistant intern
12    mentoring program within the facility for the purposes of
13    increasing education and retention, which must include an
14    experienced certified nurse assistant who has at least 3
15    years of active employment and is employed by the
16    facility.
17    (o) A facility that does not meet the requirements of
18subsection (n) shall cease its new employment training,
19education, or onboarding of any employee under the Program.
20The facility may resume its new employment training,
21education, or onboarding of an employee under the Program once
22the Department determines that the facility is in compliance
23with subsection (n).
24    (p) To study the effectiveness of the Program, the
25Department shall collect data from participating facilities
26and publish a report on the extent to which the Program brought

 

 

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1individuals into continuing employment as certified nursing
2assistants in long-term care. Data collected from facilities
3shall include, but shall not be limited to, the number of
4certified nursing assistants employed, the number of persons
5who began participation in the Program, the number of persons
6who successfully completed the Program, and the number of
7persons who continue employment in a long-term care service or
8facility. The report shall be published no later than 6 months
9after the Program end date determined under subsection (r). A
10facility participating in the Program shall, twice annually,
11submit data under this subsection in a manner and time
12determined by the Department. Failure to submit data under
13this subsection shall result in suspension of the facility's
14Program.
15    (q) The Department may adopt emergency rules in accordance
16with Section 5-45.22 of the Illinois Administrative Procedure
17Act.
18    (r) The Program shall end upon the termination of the
19Secretary of Health and Human Services' public health
20emergency declaration for COVID-19 or 3 years after the date
21that the Program becomes operational, whichever occurs later.
22    (s) This Section is inoperative 18 months after the
23Program end date determined under subsection (r).
 
24    Section 35-35. The Illinois Administrative Procedure Act
25is amended by adding Sections 5-45.21 and 5-45.22 as follows:
 

 

 

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1    (5 ILCS 100/5-45.21 new)
2    Sec. 5-45.21. Emergency rulemaking; Certified Nursing
3Assistant Intern Program; Department of Public Health. To
4provide for the expeditious and timely implementation of this
5amendatory Act of the 102nd General Assembly, emergency rules
6implementing Section 2310-434 of the Department of Public
7Health Powers and Duties Law of the Civil Administrative Code
8of Illinois may be adopted in accordance with Section 5-45 by
9the Department of Public Health. The adoption of emergency
10rules authorized by Section 5-45 and this Section is deemed to
11be necessary for the public interest, safety, and welfare.
12    This Section is repealed one year after the effective date
13of this amendatory Act of the 102nd General Assembly.
 
14    (5 ILCS 100/5-45.22 new)
15    Sec. 5-45.22. Emergency rulemaking; Certified Nursing
16Assistant Intern Program; Department of Healthcare and Family
17Services. To provide for the expeditious and timely
18implementation of this amendatory Act of the 102nd General
19Assembly, emergency rules implementing Section 5-5.01b of the
20Illinois Public Aid Code may be adopted in accordance with
21Section 5-45 by the Department of Healthcare and Family
22Services. The adoption of emergency rules authorized by
23Section 5-45 and this Section is deemed to be necessary for the
24public interest, safety, and welfare.

 

 

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1    This Section is repealed one year after the effective date
2of this amendatory Act of the 102nd General Assembly.
 
3
ARTICLE 40.

 
4    Section 40-5. The Illinois Public Aid Code is amended by
5changing Section 11-5.1 and by adding Sections 5-1.6, 5-13.1
6and 11-5.5 as follows:
 
7    (305 ILCS 5/5-1.6 new)
8    Sec. 5-1.6. Continuous eligibility; ex parte
9redeterminations.
10    (a) By July 1, 2022, the Department of Healthcare and
11Family Services shall seek a State Plan amendment or any
12federal waivers necessary to make changes to the medical
13assistance program. The Department shall apply for federal
14approval to implement 12 months of continuous eligibility for
15adults participating in the medical assistance program. The
16Department shall secure federal financial participation in
17accordance with this Section for expenditures made by the
18Department in State Fiscal Year 2023 and every State fiscal
19year thereafter.
20    (b) By July 1, 2022, the Department of Healthcare and
21Family Services shall seek a State Plan amendment or any
22federal waivers or approvals necessary to make changes to the
23medical assistance redetermination process for people without

 

 

10200HB4343sam001- 100 -LRB102 22609 KTG 38977 a

1any income at the time of redetermination. These changes shall
2seek to allow all people without income to be considered for ex
3parte redetermination. If there is no non-income related
4disqualifying information for medical assistance recipients
5without any income, then a person without any income shall be
6redetermined ex parte. Within 60 days after receiving federal
7approval or guidance, the Department of Healthcare and Family
8Services and the Department of Human Services shall make
9necessary technical and rule changes to implement changes to
10the redetermination process. The percentage of medical
11assistance recipients whose eligibility is renewed through the
12ex parte redetermination process shall be reported monthly by
13the Department of Healthcare and Family Services on its
14website in accordance with subsection (d) of Section 11-5.1 of
15this Code as well as shared in all Medicaid Advisory Committee
16meetings and Medicaid Advisory Committee Public Education
17Subcommittee meetings.
 
18    (305 ILCS 5/5-13.1 new)
19    Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers,
20and making information about waivers more accessible.
21    (a) It is the intent of the General Assembly to ease the
22burden of liens and estate recovery for correctly paid
23benefits for participants, applicants, and their families and
24heirs, and to make information about waivers more widely
25available.

 

 

10200HB4343sam001- 101 -LRB102 22609 KTG 38977 a

1    (b) The Department shall waive estate recovery under
2Sections 3-9 and 5-13 where recovery would not be
3cost-effective, would work an undue hardship, or for any other
4just reason, and shall make information about waivers and
5estate recovery easily accessible.
6        (1) Cost-effectiveness waiver. Subject to federal
7    approval, the Department shall waive any claim against the
8    first $25,000 of any estate to prevent substantial and
9    unreasonable hardship. The Department shall consider the
10    gross assets in the estate, including, but not limited to,
11    the net value of real estate less mortgages or liens with
12    priority over the Department's claims. The Department may
13    increase the cost-effectiveness threshold in the future.
14        (2) Undue hardship waiver. The Department may develop
15    additional hardship waiver standards in addition to those
16    already employed, including, but not limited to, waivers
17    aimed at preserving income-producing real property or a
18    modest home as defined by rule.
19        (3) Accessible information. The Department shall make
20    information about estate recovery and hardship waivers
21    easily accessible. The Department shall maintain
22    information about how to request a hardship waiver on its
23    website in English, Spanish, and the next 4 most commonly
24    used languages, including a short guide and simple form to
25    facilitate requesting hardship exemptions in each
26    language. On an annual basis, the Department shall

 

 

10200HB4343sam001- 102 -LRB102 22609 KTG 38977 a

1    publicly report on the number of estate recovery cases
2    that are pursued and the number of undue hardship
3    exemptions granted, including demographic data of the
4    deceased beneficiaries where available.
 
5    (305 ILCS 5/11-5.1)
6    Sec. 11-5.1. Eligibility verification. Notwithstanding any
7other provision of this Code, with respect to applications for
8medical assistance provided under Article V of this Code,
9eligibility shall be determined in a manner that ensures
10program integrity and complies with federal laws and
11regulations while minimizing unnecessary barriers to
12enrollment. To this end, as soon as practicable, and unless
13the Department receives written denial from the federal
14government, this Section shall be implemented:
15    (a) The Department of Healthcare and Family Services or
16its designees shall:
17        (1) By no later than July 1, 2011, require
18    verification of, at a minimum, one month's income from all
19    sources required for determining the eligibility of
20    applicants for medical assistance under this Code. Such
21    verification shall take the form of pay stubs, business or
22    income and expense records for self-employed persons,
23    letters from employers, and any other valid documentation
24    of income including data obtained electronically by the
25    Department or its designees from other sources as

 

 

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1    described in subsection (b) of this Section. A month's
2    income may be verified by a single pay stub with the
3    monthly income extrapolated from the time period covered
4    by the pay stub.
5        (2) By no later than October 1, 2011, require
6    verification of, at a minimum, one month's income from all
7    sources required for determining the continued eligibility
8    of recipients at their annual review of eligibility for
9    medical assistance under this Code. Information the
10    Department receives prior to the annual review, including
11    information available to the Department as a result of the
12    recipient's application for other non-Medicaid benefits,
13    that is sufficient to make a determination of continued
14    Medicaid eligibility may be reviewed and verified, and
15    subsequent action taken including client notification of
16    continued Medicaid eligibility. The date of client
17    notification establishes the date for subsequent annual
18    Medicaid eligibility reviews. Such verification shall take
19    the form of pay stubs, business or income and expense
20    records for self-employed persons, letters from employers,
21    and any other valid documentation of income including data
22    obtained electronically by the Department or its designees
23    from other sources as described in subsection (b) of this
24    Section. A month's income may be verified by a single pay
25    stub with the monthly income extrapolated from the time
26    period covered by the pay stub. The Department shall send

 

 

10200HB4343sam001- 104 -LRB102 22609 KTG 38977 a

1    a notice to recipients at least 60 days prior to the end of
2    their period of eligibility that informs them of the
3    requirements for continued eligibility. If a recipient
4    does not fulfill the requirements for continued
5    eligibility by the deadline established in the notice a
6    notice of cancellation shall be issued to the recipient
7    and coverage shall end no later than the last day of the
8    month following the last day of the eligibility period. A
9    recipient's eligibility may be reinstated without
10    requiring a new application if the recipient fulfills the
11    requirements for continued eligibility prior to the end of
12    the third month following the last date of coverage (or
13    longer period if required by federal regulations). Nothing
14    in this Section shall prevent an individual whose coverage
15    has been cancelled from reapplying for health benefits at
16    any time.
17        (3) By no later than July 1, 2011, require
18    verification of Illinois residency.
19    The Department, with federal approval, may choose to adopt
20continuous financial eligibility for a full 12 months for
21adults on Medicaid.
22    (b) The Department shall establish or continue cooperative
23arrangements with the Social Security Administration, the
24Illinois Secretary of State, the Department of Human Services,
25the Department of Revenue, the Department of Employment
26Security, and any other appropriate entity to gain electronic

 

 

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1access, to the extent allowed by law, to information available
2to those entities that may be appropriate for electronically
3verifying any factor of eligibility for benefits under the
4Program. Data relevant to eligibility shall be provided for no
5other purpose than to verify the eligibility of new applicants
6or current recipients of health benefits under the Program.
7Data shall be requested or provided for any new applicant or
8current recipient only insofar as that individual's
9circumstances are relevant to that individual's or another
10individual's eligibility.
11    (c) Within 90 days of the effective date of this
12amendatory Act of the 96th General Assembly, the Department of
13Healthcare and Family Services shall send notice to current
14recipients informing them of the changes regarding their
15eligibility verification.
16    (d) As soon as practical if the data is reasonably
17available, but no later than January 1, 2017, the Department
18shall compile on a monthly basis data on eligibility
19redeterminations of beneficiaries of medical assistance
20provided under Article V of this Code. In addition to the other
21data required under this subsection, the Department shall
22compile on a monthly basis data on the percentage of
23beneficiaries whose eligibility is renewed through ex parte
24redeterminations as described in subsection (b) of Section
255-1.6 of this Code, subject to federal approval of the changes
26made in subsection (b) of Section 5-1.6 by this amendatory Act

 

 

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1of the 102nd General Assembly. This data shall be posted on the
2Department's website, and data from prior months shall be
3retained and available on the Department's website. The data
4compiled and reported shall include the following:
5        (1) The total number of redetermination decisions made
6    in a month and, of that total number, the number of
7    decisions to continue or change benefits and the number of
8    decisions to cancel benefits.
9        (2) A breakdown of enrollee language preference for
10    the total number of redetermination decisions made in a
11    month and, of that total number, a breakdown of enrollee
12    language preference for the number of decisions to
13    continue or change benefits, and a breakdown of enrollee
14    language preference for the number of decisions to cancel
15    benefits. The language breakdown shall include, at a
16    minimum, English, Spanish, and the next 4 most commonly
17    used languages.
18        (3) The percentage of cancellation decisions made in a
19    month due to each of the following:
20            (A) The beneficiary's ineligibility due to excess
21        income.
22            (B) The beneficiary's ineligibility due to not
23        being an Illinois resident.
24            (C) The beneficiary's ineligibility due to being
25        deceased.
26            (D) The beneficiary's request to cancel benefits.

 

 

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1            (E) The beneficiary's lack of response after
2        notices mailed to the beneficiary are returned to the
3        Department as undeliverable by the United States
4        Postal Service.
5            (F) The beneficiary's lack of response to a
6        request for additional information when reliable
7        information in the beneficiary's account, or other
8        more current information, is unavailable to the
9        Department to make a decision on whether to continue
10        benefits.
11            (G) Other reasons tracked by the Department for
12        the purpose of ensuring program integrity.
13        (4) If a vendor is utilized to provide services in
14    support of the Department's redetermination decision
15    process, the total number of redetermination decisions
16    made in a month and, of that total number, the number of
17    decisions to continue or change benefits, and the number
18    of decisions to cancel benefits (i) with the involvement
19    of the vendor and (ii) without the involvement of the
20    vendor.
21        (5) Of the total number of benefit cancellations in a
22    month, the number of beneficiaries who return from
23    cancellation within one month, the number of beneficiaries
24    who return from cancellation within 2 months, and the
25    number of beneficiaries who return from cancellation
26    within 3 months. Of the number of beneficiaries who return

 

 

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1    from cancellation within 3 months, the percentage of those
2    cancellations due to each of the reasons listed under
3    paragraph (3) of this subsection.
4    (e) The Department shall conduct a complete review of the
5Medicaid redetermination process in order to identify changes
6that can increase the use of ex parte redetermination
7processing. This review shall be completed within 90 days
8after the effective date of this amendatory Act of the 101st
9General Assembly. Within 90 days of completion of the review,
10the Department shall seek written federal approval of policy
11changes the review recommended and implement once approved.
12The review shall specifically include, but not be limited to,
13use of ex parte redeterminations of the following populations:
14        (1) Recipients of developmental disabilities services.
15        (2) Recipients of benefits under the State's Aid to
16    the Aged, Blind, or Disabled program.
17        (3) Recipients of Medicaid long-term care services and
18    supports, including waiver services.
19        (4) All Modified Adjusted Gross Income (MAGI)
20    populations.
21        (5) Populations with no verifiable income.
22        (6) Self-employed people.
23    The report shall also outline populations and
24circumstances in which an ex parte redetermination is not a
25recommended option.
26    (f) The Department shall explore and implement, as

 

 

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1practical and technologically possible, roles that
2stakeholders outside State agencies can play to assist in
3expediting eligibility determinations and redeterminations
4within 24 months after the effective date of this amendatory
5Act of the 101st General Assembly. Such practical roles to be
6explored to expedite the eligibility determination processes
7shall include the implementation of hospital presumptive
8eligibility, as authorized by the Patient Protection and
9Affordable Care Act.
10    (g) The Department or its designee shall seek federal
11approval to enhance the reasonable compatibility standard from
125% to 10%.
13    (h) Reporting. The Department of Healthcare and Family
14Services and the Department of Human Services shall publish
15quarterly reports on their progress in implementing policies
16and practices pursuant to this Section as modified by this
17amendatory Act of the 101st General Assembly.
18        (1) The reports shall include, but not be limited to,
19    the following:
20            (A) Medical application processing, including a
21        breakdown of the number of MAGI, non-MAGI, long-term
22        care, and other medical cases pending for various
23        incremental time frames between 0 to 181 or more days.
24            (B) Medical redeterminations completed, including:
25        (i) a breakdown of the number of households that were
26        redetermined ex parte and those that were not; (ii)

 

 

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1        the reasons households were not redetermined ex parte;
2        and (iii) the relative percentages of these reasons.
3            (C) A narrative discussion on issues identified in
4        the functioning of the State's Integrated Eligibility
5        System and progress on addressing those issues, as
6        well as progress on implementing strategies to address
7        eligibility backlogs, including expanding ex parte
8        determinations to ensure timely eligibility
9        determinations and renewals.
10        (2) Initial reports shall be issued within 90 days
11    after the effective date of this amendatory Act of the
12    101st General Assembly.
13        (3) All reports shall be published on the Department's
14    website.
15    (i) It is the determination of the General Assembly that
16the Department must include seniors and persons with
17disabilities in ex parte renewals. It is the determination of
18the General Assembly that the Department must use its asset
19verification system to assist in the determination of whether
20an individual's coverage can be renewed using the ex parte
21process. If a State Plan amendment is required, the Department
22shall pursue such State Plan amendment by July 1, 2022. Within
2360 days after receiving federal approval or guidance, the
24Department of Healthcare and Family Services and the
25Department of Human Services shall make necessary technical
26and rule changes to implement these changes to the

 

 

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1redetermination process.
2(Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20.)
 
3    (305 ILCS 5/11-5.5 new)
4    Sec. 11-5.5. Streamlining enrollment into the Medicare
5Savings Program.
6    (a) The Department shall investigate how to align the
7Medicare Part D Low-Income Subsidy and Medicare Savings
8Program eligibility criteria.
9    (b) The Department shall issue a report making
10recommendations on how to streamline enrollment into Medicare
11Savings Program benefits by July 1, 2022.
12    (c) Within 90 days after issuing its report, the
13Department shall seek public feedback on those recommendations
14and plans.
15    (d) By July 1, 2023, the Department shall implement the
16necessary changes to streamline enrollment into the Medicare
17Savings Program. The Department may adopt any rules necessary
18to implement the provisions of this paragraph.
 
19    (305 ILCS 5/3-10 rep.)
20    (305 ILCS 5/3-10.1 rep.)
21    (305 ILCS 5/3-10.2 rep.)
22    (305 ILCS 5/3-10.3 rep.)
23    (305 ILCS 5/3-10.4 rep.)
24    (305 ILCS 5/3-10.5 rep.)

 

 

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1    (305 ILCS 5/3-10.6 rep.)
2    (305 ILCS 5/3-10.7 rep.)
3    (305 ILCS 5/3-10.8 rep.)
4    (305 ILCS 5/3-10.9 rep.)
5    (305 ILCS 5/3-10.10 rep.)
6    (305 ILCS 5/5-13.5 rep.)
7    Section 40-10. The Illinois Public Aid Code is amended by
8repealing Sections 3-10, 3-10.1, 3-10.2, 3-10.3, 3-10.4,
93-10.5, 3-10.6, 3-10.7, 3-10.8, 3-10.9, and 3-10.10, and
105-13.5.
 
11
ARTICLE 45.

 
12    Section 45-5. The Illinois Public Aid Code is amended by
13changing Section 5-5.07 as follows:
 
14    (305 ILCS 5/5-5.07)
15    Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
16rate. The Department of Children and Family Services shall pay
17the DCFS per diem rate for inpatient psychiatric stay at a
18free-standing psychiatric hospital or a hospital with a
19pediatric or adolescent inpatient psychiatric unit effective
20the 11th day when a child is in the hospital beyond medical
21necessity, and the parent or caregiver has denied the child
22access to the home and has refused or failed to make provisions
23for another living arrangement for the child or the child's

 

 

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1discharge is being delayed due to a pending inquiry or
2investigation by the Department of Children and Family
3Services. If any portion of a hospital stay is reimbursed
4under this Section, the hospital stay shall not be eligible
5for payment under the provisions of Section 14-13 of this
6Code. This Section is inoperative on and after July 1, 2021.
7Notwithstanding the provision of Public Act 101-209 stating
8that this Section is inoperative on and after July 1, 2020,
9this Section is operative from July 1, 2020 through July 1,
102023.
11(Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by
12P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21;
13102-201, eff. 7-30-21; 102-558, eff. 8-20-21.)
 
14
ARTICLE 50.

 
15    Section 50-5. The Illinois Public Aid Code is amended by
16changing Section 5-4.2 and by adding Section 5-30d as follows:
 
17    (305 ILCS 5/5-4.2)
18    Sec. 5-4.2. Ambulance services payments.
19    (a) For ambulance services provided to a recipient of aid
20under this Article on or after January 1, 1993, the Illinois
21Department shall reimburse ambulance service providers at
22rates calculated in accordance with this Section. It is the
23intent of the General Assembly to provide adequate

 

 

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

 

 

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1includes medical transportation services provided by means of
2an ambulance, medi-car, service car, or taxi.
3    (c-1) For purposes of this Section, "ground ambulance
4service" means medical transportation services that are
5described as ground ambulance services by the Centers for
6Medicare and Medicaid Services and provided in a vehicle that
7is licensed as an ambulance by the Illinois Department of
8Public Health pursuant to the Emergency Medical Services (EMS)
9Systems Act.
10    (c-2) For purposes of this Section, "ground ambulance
11service provider" means a vehicle service provider as
12described in the Emergency Medical Services (EMS) Systems Act
13that operates licensed ambulances for the purpose of providing
14emergency ambulance services, or non-emergency ambulance
15services, or both. For purposes of this Section, this includes
16both ambulance providers and ambulance suppliers as described
17by the Centers for Medicare and Medicaid Services.
18    (c-3) For purposes of this Section, "medi-car" means
19transportation services provided to a patient who is confined
20to a wheelchair and requires the use of a hydraulic or electric
21lift or ramp and wheelchair lockdown when the patient's
22condition does not require medical observation, medical
23supervision, medical equipment, the administration of
24medications, or the administration of oxygen.
25    (c-4) For purposes of this Section, "service car" means
26transportation services provided to a patient by a passenger

 

 

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1vehicle where that patient does not require the specialized
2modes described in subsection (c-1) or (c-3).
3    (d) This Section does not prohibit separate billing by
4ambulance service providers for oxygen furnished while
5providing advanced life support services.
6    (e) Beginning with services rendered on or after July 1,
72008, all providers of non-emergency medi-car and service car
8transportation must certify that the driver and employee
9attendant, as applicable, have completed a safety program
10approved by the Department to protect both the patient and the
11driver, prior to transporting a patient. The provider must
12maintain this certification in its records. The provider shall
13produce such documentation upon demand by the Department or
14its representative. Failure to produce documentation of such
15training shall result in recovery of any payments made by the
16Department for services rendered by a non-certified driver or
17employee attendant. Medi-car and service car providers must
18maintain legible documentation in their records of the driver
19and, as applicable, employee attendant that actually
20transported the patient. Providers must recertify all drivers
21and employee attendants every 3 years. If they meet the
22established training components set forth by the Department,
23providers of non-emergency medi-car and service car
24transportation that are either directly or through an
25affiliated company licensed by the Department of Public Health
26shall be approved by the Department to have in-house safety

 

 

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1programs for training their own staff.
2    Notwithstanding the requirements above, any public
3transportation provider of medi-car and service car
4transportation that receives federal funding under 49 U.S.C.
55307 and 5311 need not certify its drivers and employee
6attendants under this Section, since safety training is
7already federally mandated.
8    (f) With respect to any policy or program administered by
9the Department or its agent regarding approval of
10non-emergency medical transportation by ground ambulance
11service providers, including, but not limited to, the
12Non-Emergency Transportation Services Prior Approval Program
13(NETSPAP), the Department shall establish by rule a process by
14which ground ambulance service providers of non-emergency
15medical transportation may appeal any decision by the
16Department or its agent for which no denial was received prior
17to the time of transport that either (i) denies a request for
18approval for payment of non-emergency transportation by means
19of ground ambulance service or (ii) grants a request for
20approval of non-emergency transportation by means of ground
21ambulance service at a level of service that entitles the
22ground ambulance service provider to a lower level of
23compensation from the Department than the ground ambulance
24service provider would have received as compensation for the
25level of service requested. The rule shall be filed by
26December 15, 2012 and shall provide that, for any decision

 

 

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1rendered by the Department or its agent on or after the date
2the rule takes effect, the ground ambulance service provider
3shall have 60 days from the date the decision is received to
4file an appeal. The rule established by the Department shall
5be, insofar as is practical, consistent with the Illinois
6Administrative Procedure Act. The Director's decision on an
7appeal under this Section shall be a final administrative
8decision subject to review under the Administrative Review
9Law.
10    (f-5) Beginning 90 days after July 20, 2012 (the effective
11date of Public Act 97-842), (i) no denial of a request for
12approval for payment of non-emergency transportation by means
13of ground ambulance service, and (ii) no approval of
14non-emergency transportation by means of ground ambulance
15service at a level of service that entitles the ground
16ambulance service provider to a lower level of compensation
17from the Department than would have been received at the level
18of service submitted by the ground ambulance service provider,
19may be issued by the Department or its agent unless the
20Department has submitted the criteria for determining the
21appropriateness of the transport for first notice publication
22in the Illinois Register pursuant to Section 5-40 of the
23Illinois Administrative Procedure Act.
24    (f-6) Within 90 days after the effective date of this
25amendatory Act of the 102nd General Assembly and subject to
26federal approval, the Department shall file rules to allow for

 

 

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1the approval of ground ambulance services when the sole
2purpose of the transport is for the navigation of stairs or the
3assisting or lifting of a patient at a medical facility or
4during a medical appointment in instances where the Department
5or a contracted Medicaid managed care organization or their
6transportation broker is unable to secure transportation
7through any other transportation provider.
8    (f-7) For non-emergency ground ambulance claims properly
9denied under Department policy at the time the claim is filed
10due to failure to submit a valid Medical Certification for
11Non-Emergency Ambulance on and after December 15, 2012 and
12prior to January 1, 2021, the Department shall allot
13$2,000,000 to a pool to reimburse such claims if the provider
14proves medical necessity for the service by other means.
15Providers must submit any such denied claims for which they
16seek compensation to the Department no later than December 31,
172021 along with documentation of medical necessity. No later
18than May 31, 2022, the Department shall determine for which
19claims medical necessity was established. Such claims for
20which medical necessity was established shall be paid at the
21rate in effect at the time of the service, provided the
22$2,000,000 is sufficient to pay at those rates. If the pool is
23not sufficient, claims shall be paid at a uniform percentage
24of the applicable rate such that the pool of $2,000,000 is
25exhausted. The appeal process described in subsection (f)
26shall not be applicable to the Department's determinations

 

 

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1made in accordance with this subsection.
2    (g) Whenever a patient covered by a medical assistance
3program under this Code or by another medical program
4administered by the Department, including a patient covered
5under the State's Medicaid managed care program, is being
6transported from a facility and requires non-emergency
7transportation including ground ambulance, medi-car, or
8service car transportation, a Physician Certification
9Statement as described in this Section shall be required for
10each patient. Facilities shall develop procedures for a
11licensed medical professional to provide a written and signed
12Physician Certification Statement. The Physician Certification
13Statement shall specify the level of transportation services
14needed and complete a medical certification establishing the
15criteria for approval of non-emergency ambulance
16transportation, as published by the Department of Healthcare
17and Family Services, that is met by the patient. This
18certification shall be completed prior to ordering the
19transportation service and prior to patient discharge. The
20Physician Certification Statement is not required prior to
21transport if a delay in transport can be expected to
22negatively affect the patient outcome. If the ground ambulance
23provider, medi-car provider, or service car provider is unable
24to obtain the required Physician Certification Statement
25within 10 calendar days following the date of the service, the
26ground ambulance provider, medi-car provider, or service car

 

 

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1provider must document its attempt to obtain the requested
2certification and may then submit the claim for payment.
3Acceptable documentation includes a signed return receipt from
4the U.S. Postal Service, facsimile receipt, email receipt, or
5other similar service that evidences that the ground ambulance
6provider, medi-car provider, or service car provider attempted
7to obtain the required Physician Certification Statement.
8    The medical certification specifying the level and type of
9non-emergency transportation needed shall be in the form of
10the Physician Certification Statement on a standardized form
11prescribed by the Department of Healthcare and Family
12Services. Within 75 days after July 27, 2018 (the effective
13date of Public Act 100-646), the Department of Healthcare and
14Family Services shall develop a standardized form of the
15Physician Certification Statement specifying the level and
16type of transportation services needed in consultation with
17the Department of Public Health, Medicaid managed care
18organizations, a statewide association representing ambulance
19providers, a statewide association representing hospitals, 3
20statewide associations representing nursing homes, and other
21stakeholders. The Physician Certification Statement shall
22include, but is not limited to, the criteria necessary to
23demonstrate medical necessity for the level of transport
24needed as required by (i) the Department of Healthcare and
25Family Services and (ii) the federal Centers for Medicare and
26Medicaid Services as outlined in the Centers for Medicare and

 

 

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1Medicaid Services' Medicare Benefit Policy Manual, Pub.
2100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
3Certification Statement shall satisfy the obligations of
4hospitals under Section 6.22 of the Hospital Licensing Act and
5nursing homes under Section 2-217 of the Nursing Home Care
6Act. Implementation and acceptance of the Physician
7Certification Statement shall take place no later than 90 days
8after the issuance of the Physician Certification Statement by
9the Department of Healthcare and Family Services.
10    Pursuant to subsection (E) of Section 12-4.25 of this
11Code, the Department is entitled to recover overpayments paid
12to a provider or vendor, including, but not limited to, from
13the discharging physician, the discharging facility, and the
14ground ambulance service provider, in instances where a
15non-emergency ground ambulance service is rendered as the
16result of improper or false certification.
17    Beginning October 1, 2018, the Department of Healthcare
18and Family Services shall collect data from Medicaid managed
19care organizations and transportation brokers, including the
20Department's NETSPAP broker, regarding denials and appeals
21related to the missing or incomplete Physician Certification
22Statement forms and overall compliance with this subsection.
23The Department of Healthcare and Family Services shall publish
24quarterly results on its website within 15 days following the
25end of each quarter.
26    (h) On and after July 1, 2012, the Department shall reduce

 

 

10200HB4343sam001- 123 -LRB102 22609 KTG 38977 a

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    (i) On and after July 1, 2018, the Department shall
6increase the base rate of reimbursement for both base charges
7and mileage charges for ground ambulance service providers for
8medical transportation services provided by means of a ground
9ambulance to a level not lower than 112% of the base rate in
10effect as of June 30, 2018.
11(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
12102-364, eff. 1-1-22; 102-650, eff. 8-27-21; revised 11-8-21.)
 
13    (305 ILCS 5/5-30d new)
14    Sec. 5-30d. Increased funding for transportation services.
15Beginning no later than January 1, 2023 and subject to federal
16approval, the amount allocated to fund rates for medi-car,
17service car, and attendant services provided to adults and
18children under the medical assistance program shall be
19increased by an approximate amount of $24,000,000.
 
20
ARTICLE 999.

 
21    Section 999-99. Effective date. This Act takes effect upon
22becoming law.".