Rep. Robyn Gabel
Filed: 5/25/2024
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1 | AMENDMENT TO SENATE BILL 3268 | ||||||
2 | AMENDMENT NO. ______. Amend Senate Bill 3268, AS AMENDED, | ||||||
3 | by replacing everything after the enacting clause with the | ||||||
4 | following: | ||||||
5 | "ARTICLE 5. | ||||||
6 | Section 5-5. The Illinois Public Aid Code is amended by | ||||||
7 | changing Section 5-5 as follows: | ||||||
8 | (305 ILCS 5/5-5) | ||||||
9 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
10 | rule, shall determine the quantity and quality of and the rate | ||||||
11 | of reimbursement for the medical assistance for which payment | ||||||
12 | will be authorized, and the medical services to be provided, | ||||||
13 | which may include all or part of the following: (1) inpatient | ||||||
14 | hospital services; (2) outpatient hospital services; (3) other | ||||||
15 | laboratory and X-ray services; (4) skilled nursing home |
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1 | services; (5) physicians' services whether furnished in the | ||||||
2 | office, the patient's home, a hospital, a skilled nursing | ||||||
3 | home, or elsewhere; (6) medical care, or any other type of | ||||||
4 | remedial care furnished by licensed practitioners; (7) home | ||||||
5 | health care services; (8) private duty nursing service; (9) | ||||||
6 | clinic services; (10) dental services, including prevention | ||||||
7 | and treatment of periodontal disease and dental caries disease | ||||||
8 | for pregnant individuals, provided by an individual licensed | ||||||
9 | to practice dentistry or dental surgery; for purposes of this | ||||||
10 | item (10), "dental services" means diagnostic, preventive, or | ||||||
11 | corrective procedures provided by or under the supervision of | ||||||
12 | a dentist in the practice of his or her profession; (11) | ||||||
13 | physical therapy and related services; (12) prescribed drugs, | ||||||
14 | dentures, and prosthetic devices; and eyeglasses prescribed by | ||||||
15 | a physician skilled in the diseases of the eye, or by an | ||||||
16 | optometrist, whichever the person may select; (13) other | ||||||
17 | diagnostic, screening, preventive, and rehabilitative | ||||||
18 | services, including to ensure that the individual's need for | ||||||
19 | intervention or treatment of mental disorders or substance use | ||||||
20 | disorders or co-occurring mental health and substance use | ||||||
21 | disorders is determined using a uniform screening, assessment, | ||||||
22 | and evaluation process inclusive of criteria, for children and | ||||||
23 | adults; for purposes of this item (13), a uniform screening, | ||||||
24 | assessment, and evaluation process refers to a process that | ||||||
25 | includes an appropriate evaluation and, as warranted, a | ||||||
26 | referral; "uniform" does not mean the use of a singular |
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1 | instrument, tool, or process that all must utilize; (14) | ||||||
2 | transportation and such other expenses as may be necessary; | ||||||
3 | (15) medical treatment of sexual assault survivors, as defined | ||||||
4 | in Section 1a of the Sexual Assault Survivors Emergency | ||||||
5 | Treatment Act, for injuries sustained as a result of the | ||||||
6 | sexual assault, including examinations and laboratory tests to | ||||||
7 | discover evidence which may be used in criminal proceedings | ||||||
8 | arising from the sexual assault; (16) the diagnosis and | ||||||
9 | treatment of sickle cell anemia; (16.5) services performed by | ||||||
10 | a chiropractic physician licensed under the Medical Practice | ||||||
11 | Act of 1987 and acting within the scope of his or her license, | ||||||
12 | including, but not limited to, chiropractic manipulative | ||||||
13 | treatment; and (17) any other medical care, and any other type | ||||||
14 | of remedial care recognized under the laws of this State. The | ||||||
15 | term "any other type of remedial care" shall include nursing | ||||||
16 | care and nursing home service for persons who rely on | ||||||
17 | treatment by spiritual means alone through prayer for healing. | ||||||
18 | Notwithstanding any other provision of this Section, a | ||||||
19 | comprehensive tobacco use cessation program that includes | ||||||
20 | purchasing prescription drugs or prescription medical devices | ||||||
21 | approved by the Food and Drug Administration shall be covered | ||||||
22 | under the medical assistance program under this Article for | ||||||
23 | persons who are otherwise eligible for assistance under this | ||||||
24 | Article. | ||||||
25 | Notwithstanding any other provision of this Code, | ||||||
26 | reproductive health care that is otherwise legal in Illinois |
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1 | shall be covered under the medical assistance program for | ||||||
2 | persons who are otherwise eligible for medical assistance | ||||||
3 | under this Article. | ||||||
4 | Notwithstanding any other provision of this Section, all | ||||||
5 | tobacco cessation medications approved by the United States | ||||||
6 | Food and Drug Administration and all individual and group | ||||||
7 | tobacco cessation counseling services and telephone-based | ||||||
8 | counseling services and tobacco cessation medications provided | ||||||
9 | through the Illinois Tobacco Quitline shall be covered under | ||||||
10 | the medical assistance program for persons who are otherwise | ||||||
11 | eligible for assistance under this Article. The Department | ||||||
12 | shall comply with all federal requirements necessary to obtain | ||||||
13 | federal financial participation, as specified in 42 CFR | ||||||
14 | 433.15(b)(7), for telephone-based counseling services provided | ||||||
15 | through the Illinois Tobacco Quitline, including, but not | ||||||
16 | limited to: (i) entering into a memorandum of understanding or | ||||||
17 | interagency agreement with the Department of Public Health, as | ||||||
18 | administrator of the Illinois Tobacco Quitline; and (ii) | ||||||
19 | developing a cost allocation plan for Medicaid-allowable | ||||||
20 | Illinois Tobacco Quitline services in accordance with 45 CFR | ||||||
21 | 95.507. The Department shall submit the memorandum of | ||||||
22 | understanding or interagency agreement, the cost allocation | ||||||
23 | plan, and all other necessary documentation to the Centers for | ||||||
24 | Medicare and Medicaid Services for review and approval. | ||||||
25 | Coverage under this paragraph shall be contingent upon federal | ||||||
26 | approval. |
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1 | Notwithstanding any other provision of this Code, the | ||||||
2 | Illinois Department may not require, as a condition of payment | ||||||
3 | for any laboratory test authorized under this Article, that a | ||||||
4 | physician's handwritten signature appear on the laboratory | ||||||
5 | test order form. The Illinois Department may, however, impose | ||||||
6 | other appropriate requirements regarding laboratory test order | ||||||
7 | documentation. | ||||||
8 | Upon receipt of federal approval of an amendment to the | ||||||
9 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
10 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
11 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
12 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
13 | that its vendor or vendors are enrolled as providers in the | ||||||
14 | medical assistance program and in any capitated Medicaid | ||||||
15 | managed care entity (MCE) serving individuals enrolled in a | ||||||
16 | school within the CPS system. Under any contract procured | ||||||
17 | under this provision, the vendor or vendors must serve only | ||||||
18 | individuals enrolled in a school within the CPS system. Claims | ||||||
19 | for services provided by CPS's vendor or vendors to recipients | ||||||
20 | of benefits in the medical assistance program under this Code, | ||||||
21 | the Children's Health Insurance Program, or the Covering ALL | ||||||
22 | KIDS Health Insurance Program shall be submitted to the | ||||||
23 | Department or the MCE in which the individual is enrolled for | ||||||
24 | payment and shall be reimbursed at the Department's or the | ||||||
25 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
26 | On and after July 1, 2012, the Department of Healthcare |
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1 | and Family Services may provide the following services to | ||||||
2 | persons eligible for assistance under this Article who are | ||||||
3 | participating in education, training or employment programs | ||||||
4 | operated by the Department of Human Services as successor to | ||||||
5 | the Department of Public Aid: | ||||||
6 | (1) dental services provided by or under the | ||||||
7 | supervision of a dentist; and | ||||||
8 | (2) eyeglasses prescribed by a physician skilled in | ||||||
9 | the diseases of the eye, or by an optometrist, whichever | ||||||
10 | the person may select. | ||||||
11 | On and after July 1, 2018, the Department of Healthcare | ||||||
12 | and Family Services shall provide dental services to any adult | ||||||
13 | who is otherwise eligible for assistance under the medical | ||||||
14 | assistance program. As used in this paragraph, "dental | ||||||
15 | services" means diagnostic, preventative, restorative, or | ||||||
16 | corrective procedures, including procedures and services for | ||||||
17 | the prevention and treatment of periodontal disease and dental | ||||||
18 | caries disease, provided by an individual who is licensed to | ||||||
19 | practice dentistry or dental surgery or who is under the | ||||||
20 | supervision of a dentist in the practice of his or her | ||||||
21 | profession. | ||||||
22 | On and after July 1, 2018, targeted dental services, as | ||||||
23 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
24 | United States District Court for the Northern District of | ||||||
25 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
26 | Maram, Case No. 92 C 1982, that are provided to adults under |
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1 | the medical assistance program shall be established at no less | ||||||
2 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
3 | of the Consent Decree for targeted dental services that are | ||||||
4 | provided to persons under the age of 18 under the medical | ||||||
5 | assistance program. | ||||||
6 | Subject to federal approval, on and after January 1, 2025, | ||||||
7 | the rates paid for sedation evaluation and the provision of | ||||||
8 | deep sedation and intravenous sedation for the purpose of | ||||||
9 | dental services shall be increased by 33% above the rates in | ||||||
10 | effect on December 31, 2024. The rates paid for nitrous oxide | ||||||
11 | sedation shall not be impacted by this paragraph and shall | ||||||
12 | remain the same as the rates in effect on December 31, 2024. | ||||||
13 | Notwithstanding any other provision of this Code and | ||||||
14 | subject to federal approval, the Department may adopt rules to | ||||||
15 | allow a dentist who is volunteering his or her service at no | ||||||
16 | cost to render dental services through an enrolled | ||||||
17 | not-for-profit health clinic without the dentist personally | ||||||
18 | enrolling as a participating provider in the medical | ||||||
19 | assistance program. A not-for-profit health clinic shall | ||||||
20 | include a public health clinic or Federally Qualified Health | ||||||
21 | Center or other enrolled provider, as determined by the | ||||||
22 | Department, through which dental services covered under this | ||||||
23 | Section are performed. The Department shall establish a | ||||||
24 | process for payment of claims for reimbursement for covered | ||||||
25 | dental services rendered under this provision. | ||||||
26 | On and after January 1, 2022, the Department of Healthcare |
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1 | and Family Services shall administer and regulate a | ||||||
2 | school-based dental program that allows for the out-of-office | ||||||
3 | delivery of preventative dental services in a school setting | ||||||
4 | to children under 19 years of age. The Department shall | ||||||
5 | establish, by rule, guidelines for participation by providers | ||||||
6 | and set requirements for follow-up referral care based on the | ||||||
7 | requirements established in the Dental Office Reference Manual | ||||||
8 | published by the Department that establishes the requirements | ||||||
9 | for dentists participating in the All Kids Dental School | ||||||
10 | Program. Every effort shall be made by the Department when | ||||||
11 | developing the program requirements to consider the different | ||||||
12 | geographic differences of both urban and rural areas of the | ||||||
13 | State for initial treatment and necessary follow-up care. No | ||||||
14 | provider shall be charged a fee by any unit of local government | ||||||
15 | to participate in the school-based dental program administered | ||||||
16 | by the Department. Nothing in this paragraph shall be | ||||||
17 | construed to limit or preempt a home rule unit's or school | ||||||
18 | district's authority to establish, change, or administer a | ||||||
19 | school-based dental program in addition to, or independent of, | ||||||
20 | the school-based dental program administered by the | ||||||
21 | Department. | ||||||
22 | The Illinois Department, by rule, may distinguish and | ||||||
23 | classify the medical services to be provided only in | ||||||
24 | accordance with the classes of persons designated in Section | ||||||
25 | 5-2. | ||||||
26 | The Department of Healthcare and Family Services must |
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1 | provide coverage and reimbursement for amino acid-based | ||||||
2 | elemental formulas, regardless of delivery method, for the | ||||||
3 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
4 | short bowel syndrome when the prescribing physician has issued | ||||||
5 | a written order stating that the amino acid-based elemental | ||||||
6 | formula is medically necessary. | ||||||
7 | The Illinois Department shall authorize the provision of, | ||||||
8 | and shall authorize payment for, screening by low-dose | ||||||
9 | mammography for the presence of occult breast cancer for | ||||||
10 | individuals 35 years of age or older who are eligible for | ||||||
11 | medical assistance under this Article, as follows: | ||||||
12 | (A) A baseline mammogram for individuals 35 to 39 | ||||||
13 | years of age. | ||||||
14 | (B) An annual mammogram for individuals 40 years of | ||||||
15 | age or older. | ||||||
16 | (C) A mammogram at the age and intervals considered | ||||||
17 | medically necessary by the individual's health care | ||||||
18 | provider for individuals under 40 years of age and having | ||||||
19 | a family history of breast cancer, prior personal history | ||||||
20 | of breast cancer, positive genetic testing, or other risk | ||||||
21 | factors. | ||||||
22 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
23 | entire breast or breasts if a mammogram demonstrates | ||||||
24 | heterogeneous or dense breast tissue or when medically | ||||||
25 | necessary as determined by a physician licensed to | ||||||
26 | practice medicine in all of its branches. |
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1 | (E) A screening MRI when medically necessary, as | ||||||
2 | determined by a physician licensed to practice medicine in | ||||||
3 | all of its branches. | ||||||
4 | (F) A diagnostic mammogram when medically necessary, | ||||||
5 | as determined by a physician licensed to practice medicine | ||||||
6 | in all its branches, advanced practice registered nurse, | ||||||
7 | or physician assistant. | ||||||
8 | The Department shall not impose a deductible, coinsurance, | ||||||
9 | copayment, or any other cost-sharing requirement on the | ||||||
10 | coverage provided under this paragraph; except that this | ||||||
11 | sentence does not apply to coverage of diagnostic mammograms | ||||||
12 | to the extent such coverage would disqualify a high-deductible | ||||||
13 | health plan from eligibility for a health savings account | ||||||
14 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
15 | U.S.C. 223). | ||||||
16 | All screenings shall include a physical breast exam, | ||||||
17 | instruction on self-examination and information regarding the | ||||||
18 | frequency of self-examination and its value as a preventative | ||||||
19 | tool. | ||||||
20 | For purposes of this Section: | ||||||
21 | "Diagnostic mammogram" means a mammogram obtained using | ||||||
22 | diagnostic mammography. | ||||||
23 | "Diagnostic mammography" means a method of screening that | ||||||
24 | is designed to evaluate an abnormality in a breast, including | ||||||
25 | an abnormality seen or suspected on a screening mammogram or a | ||||||
26 | subjective or objective abnormality otherwise detected in the |
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1 | breast. | ||||||
2 | "Low-dose mammography" means the x-ray examination of the | ||||||
3 | breast using equipment dedicated specifically for mammography, | ||||||
4 | including the x-ray tube, filter, compression device, and | ||||||
5 | image receptor, with an average radiation exposure delivery of | ||||||
6 | less than one rad per breast for 2 views of an average size | ||||||
7 | breast. The term also includes digital mammography and | ||||||
8 | includes breast tomosynthesis. | ||||||
9 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
10 | involves the acquisition of projection images over the | ||||||
11 | stationary breast to produce cross-sectional digital | ||||||
12 | three-dimensional images of the breast. | ||||||
13 | If, at any time, the Secretary of the United States | ||||||
14 | Department of Health and Human Services, or its successor | ||||||
15 | agency, promulgates rules or regulations to be published in | ||||||
16 | the Federal Register or publishes a comment in the Federal | ||||||
17 | Register or issues an opinion, guidance, or other action that | ||||||
18 | would require the State, pursuant to any provision of the | ||||||
19 | Patient Protection and Affordable Care Act (Public Law | ||||||
20 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
21 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
22 | of any coverage for breast tomosynthesis outlined in this | ||||||
23 | paragraph, then the requirement that an insurer cover breast | ||||||
24 | tomosynthesis is inoperative other than any such coverage | ||||||
25 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
26 | U.S.C. 1396a, and the State shall not assume any obligation |
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1 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
2 | this paragraph. | ||||||
3 | On and after January 1, 2016, the Department shall ensure | ||||||
4 | that all networks of care for adult clients of the Department | ||||||
5 | include access to at least one breast imaging Center of | ||||||
6 | Imaging Excellence as certified by the American College of | ||||||
7 | Radiology. | ||||||
8 | On and after January 1, 2012, providers participating in a | ||||||
9 | quality improvement program approved by the Department shall | ||||||
10 | be reimbursed for screening and diagnostic mammography at the | ||||||
11 | same rate as the Medicare program's rates, including the | ||||||
12 | increased reimbursement for digital mammography and, after | ||||||
13 | January 1, 2023 (the effective date of Public Act 102-1018), | ||||||
14 | breast tomosynthesis. | ||||||
15 | The Department shall convene an expert panel including | ||||||
16 | representatives of hospitals, free-standing mammography | ||||||
17 | facilities, and doctors, including radiologists, to establish | ||||||
18 | quality standards for mammography. | ||||||
19 | On and after January 1, 2017, providers participating in a | ||||||
20 | breast cancer treatment quality improvement program approved | ||||||
21 | by the Department shall be reimbursed for breast cancer | ||||||
22 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
23 | program's rates for the data elements included in the breast | ||||||
24 | cancer treatment quality program. | ||||||
25 | The Department shall convene an expert panel, including | ||||||
26 | representatives of hospitals, free-standing breast cancer |
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1 | treatment centers, breast cancer quality organizations, and | ||||||
2 | doctors, including breast surgeons, reconstructive breast | ||||||
3 | surgeons, oncologists, and primary care providers to establish | ||||||
4 | quality standards for breast cancer treatment. | ||||||
5 | Subject to federal approval, the Department shall | ||||||
6 | establish a rate methodology for mammography at federally | ||||||
7 | qualified health centers and other encounter-rate clinics. | ||||||
8 | These clinics or centers may also collaborate with other | ||||||
9 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
10 | Department shall report to the General Assembly on the status | ||||||
11 | of the provision set forth in this paragraph. | ||||||
12 | The Department shall establish a methodology to remind | ||||||
13 | individuals who are age-appropriate for screening mammography, | ||||||
14 | but who have not received a mammogram within the previous 18 | ||||||
15 | months, of the importance and benefit of screening | ||||||
16 | mammography. The Department shall work with experts in breast | ||||||
17 | cancer outreach and patient navigation to optimize these | ||||||
18 | reminders and shall establish a methodology for evaluating | ||||||
19 | their effectiveness and modifying the methodology based on the | ||||||
20 | evaluation. | ||||||
21 | The Department shall establish a performance goal for | ||||||
22 | primary care providers with respect to their female patients | ||||||
23 | over age 40 receiving an annual mammogram. This performance | ||||||
24 | goal shall be used to provide additional reimbursement in the | ||||||
25 | form of a quality performance bonus to primary care providers | ||||||
26 | who meet that goal. |
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1 | The Department shall devise a means of case-managing or | ||||||
2 | patient navigation for beneficiaries diagnosed with breast | ||||||
3 | cancer. This program shall initially operate as a pilot | ||||||
4 | program in areas of the State with the highest incidence of | ||||||
5 | mortality related to breast cancer. At least one pilot program | ||||||
6 | site shall be in the metropolitan Chicago area and at least one | ||||||
7 | site shall be outside the metropolitan Chicago area. On or | ||||||
8 | after July 1, 2016, the pilot program shall be expanded to | ||||||
9 | include one site in western Illinois, one site in southern | ||||||
10 | Illinois, one site in central Illinois, and 4 sites within | ||||||
11 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
12 | be carried out measuring health outcomes and cost of care for | ||||||
13 | those served by the pilot program compared to similarly | ||||||
14 | situated patients who are not served by the pilot program. | ||||||
15 | The Department shall require all networks of care to | ||||||
16 | develop a means either internally or by contract with experts | ||||||
17 | in navigation and community outreach to navigate cancer | ||||||
18 | patients to comprehensive care in a timely fashion. The | ||||||
19 | Department shall require all networks of care to include | ||||||
20 | access for patients diagnosed with cancer to at least one | ||||||
21 | academic commission on cancer-accredited cancer program as an | ||||||
22 | in-network covered benefit. | ||||||
23 | The Department shall provide coverage and reimbursement | ||||||
24 | for a human papillomavirus (HPV) vaccine that is approved for | ||||||
25 | marketing by the federal Food and Drug Administration for all | ||||||
26 | persons between the ages of 9 and 45. Subject to federal |
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1 | approval, the Department shall provide coverage and | ||||||
2 | reimbursement for a human papillomavirus (HPV) vaccine for | ||||||
3 | persons of the age of 46 and above who have been diagnosed with | ||||||
4 | cervical dysplasia with a high risk of recurrence or | ||||||
5 | progression. The Department shall disallow any | ||||||
6 | preauthorization requirements for the administration of the | ||||||
7 | human papillomavirus (HPV) vaccine. | ||||||
8 | On or after July 1, 2022, individuals who are otherwise | ||||||
9 | eligible for medical assistance under this Article shall | ||||||
10 | receive coverage for perinatal depression screenings for the | ||||||
11 | 12-month period beginning on the last day of their pregnancy. | ||||||
12 | Medical assistance coverage under this paragraph shall be | ||||||
13 | conditioned on the use of a screening instrument approved by | ||||||
14 | the Department. | ||||||
15 | Any medical or health care provider shall immediately | ||||||
16 | recommend, to any pregnant individual who is being provided | ||||||
17 | prenatal services and is suspected of having a substance use | ||||||
18 | disorder as defined in the Substance Use Disorder Act, | ||||||
19 | referral to a local substance use disorder treatment program | ||||||
20 | licensed by the Department of Human Services or to a licensed | ||||||
21 | hospital which provides substance abuse treatment services. | ||||||
22 | The Department of Healthcare and Family Services shall assure | ||||||
23 | coverage for the cost of treatment of the drug abuse or | ||||||
24 | addiction for pregnant recipients in accordance with the | ||||||
25 | Illinois Medicaid Program in conjunction with the Department | ||||||
26 | of Human Services. |
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1 | All medical providers providing medical assistance to | ||||||
2 | pregnant individuals under this Code shall receive information | ||||||
3 | from the Department on the availability of services under any | ||||||
4 | program providing case management services for addicted | ||||||
5 | individuals, including information on appropriate referrals | ||||||
6 | for other social services that may be needed by addicted | ||||||
7 | individuals in addition to treatment for addiction. | ||||||
8 | The Illinois Department, in cooperation with the | ||||||
9 | Departments of Human Services (as successor to the Department | ||||||
10 | of Alcoholism and Substance Abuse) and Public Health, through | ||||||
11 | a public awareness campaign, may provide information | ||||||
12 | concerning treatment for alcoholism and drug abuse and | ||||||
13 | addiction, prenatal health care, and other pertinent programs | ||||||
14 | directed at reducing the number of drug-affected infants born | ||||||
15 | to recipients of medical assistance. | ||||||
16 | Neither the Department of Healthcare and Family Services | ||||||
17 | nor the Department of Human Services shall sanction the | ||||||
18 | recipient solely on the basis of the recipient's substance | ||||||
19 | abuse. | ||||||
20 | The Illinois Department shall establish such regulations | ||||||
21 | governing the dispensing of health services under this Article | ||||||
22 | as it shall deem appropriate. The Department should seek the | ||||||
23 | advice of formal professional advisory committees appointed by | ||||||
24 | the Director of the Illinois Department for the purpose of | ||||||
25 | providing regular advice on policy and administrative matters, | ||||||
26 | information dissemination and educational activities for |
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1 | medical and health care providers, and consistency in | ||||||
2 | procedures to the Illinois Department. | ||||||
3 | The Illinois Department may develop and contract with | ||||||
4 | Partnerships of medical providers to arrange medical services | ||||||
5 | for persons eligible under Section 5-2 of this Code. | ||||||
6 | Implementation of this Section may be by demonstration | ||||||
7 | projects in certain geographic areas. The Partnership shall be | ||||||
8 | represented by a sponsor organization. The Department, by | ||||||
9 | rule, shall develop qualifications for sponsors of | ||||||
10 | Partnerships. Nothing in this Section shall be construed to | ||||||
11 | require that the sponsor organization be a medical | ||||||
12 | organization. | ||||||
13 | The sponsor must negotiate formal written contracts with | ||||||
14 | medical providers for physician services, inpatient and | ||||||
15 | outpatient hospital care, home health services, treatment for | ||||||
16 | alcoholism and substance abuse, and other services determined | ||||||
17 | necessary by the Illinois Department by rule for delivery by | ||||||
18 | Partnerships. Physician services must include prenatal and | ||||||
19 | obstetrical care. The Illinois Department shall reimburse | ||||||
20 | medical services delivered by Partnership providers to clients | ||||||
21 | in target areas according to provisions of this Article and | ||||||
22 | the Illinois Health Finance Reform Act, except that: | ||||||
23 | (1) Physicians participating in a Partnership and | ||||||
24 | providing certain services, which shall be determined by | ||||||
25 | the Illinois Department, to persons in areas covered by | ||||||
26 | the Partnership may receive an additional surcharge for |
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1 | such services. | ||||||
2 | (2) The Department may elect to consider and negotiate | ||||||
3 | financial incentives to encourage the development of | ||||||
4 | Partnerships and the efficient delivery of medical care. | ||||||
5 | (3) Persons receiving medical services through | ||||||
6 | Partnerships may receive medical and case management | ||||||
7 | services above the level usually offered through the | ||||||
8 | medical assistance program. | ||||||
9 | Medical providers shall be required to meet certain | ||||||
10 | qualifications to participate in Partnerships to ensure the | ||||||
11 | delivery of high quality medical services. These | ||||||
12 | qualifications shall be determined by rule of the Illinois | ||||||
13 | Department and may be higher than qualifications for | ||||||
14 | participation in the medical assistance program. Partnership | ||||||
15 | sponsors may prescribe reasonable additional qualifications | ||||||
16 | for participation by medical providers, only with the prior | ||||||
17 | written approval of the Illinois Department. | ||||||
18 | Nothing in this Section shall limit the free choice of | ||||||
19 | practitioners, hospitals, and other providers of medical | ||||||
20 | services by clients. In order to ensure patient freedom of | ||||||
21 | choice, the Illinois Department shall immediately promulgate | ||||||
22 | all rules and take all other necessary actions so that | ||||||
23 | provided services may be accessed from therapeutically | ||||||
24 | certified optometrists to the full extent of the Illinois | ||||||
25 | Optometric Practice Act of 1987 without discriminating between | ||||||
26 | service providers. |
| |||||||
| |||||||
1 | The Department shall apply for a waiver from the United | ||||||
2 | States Health Care Financing Administration to allow for the | ||||||
3 | implementation of Partnerships under this Section. | ||||||
4 | The Illinois Department shall require health care | ||||||
5 | providers to maintain records that document the medical care | ||||||
6 | and services provided to recipients of Medical Assistance | ||||||
7 | under this Article. Such records must be retained for a period | ||||||
8 | of not less than 6 years from the date of service or as | ||||||
9 | provided by applicable State law, whichever period is longer, | ||||||
10 | except that if an audit is initiated within the required | ||||||
11 | retention period then the records must be retained until the | ||||||
12 | audit is completed and every exception is resolved. The | ||||||
13 | Illinois Department shall require health care providers to | ||||||
14 | make available, when authorized by the patient, in writing, | ||||||
15 | the medical records in a timely fashion to other health care | ||||||
16 | providers who are treating or serving persons eligible for | ||||||
17 | Medical Assistance under this Article. All dispensers of | ||||||
18 | medical services shall be required to maintain and retain | ||||||
19 | business and professional records sufficient to fully and | ||||||
20 | accurately document the nature, scope, details and receipt of | ||||||
21 | the health care provided to persons eligible for medical | ||||||
22 | assistance under this Code, in accordance with regulations | ||||||
23 | promulgated by the Illinois Department. The rules and | ||||||
24 | regulations shall require that proof of the receipt of | ||||||
25 | prescription drugs, dentures, prosthetic devices and | ||||||
26 | eyeglasses by eligible persons under this Section accompany |
| |||||||
| |||||||
1 | each claim for reimbursement submitted by the dispenser of | ||||||
2 | such medical services. No such claims for reimbursement shall | ||||||
3 | be approved for payment by the Illinois Department without | ||||||
4 | such proof of receipt, unless the Illinois Department shall | ||||||
5 | have put into effect and shall be operating a system of | ||||||
6 | post-payment audit and review which shall, on a sampling | ||||||
7 | basis, be deemed adequate by the Illinois Department to assure | ||||||
8 | that such drugs, dentures, prosthetic devices and eyeglasses | ||||||
9 | for which payment is being made are actually being received by | ||||||
10 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
11 | (the effective date of Public Act 83-1439), the Illinois | ||||||
12 | Department shall establish a current list of acquisition costs | ||||||
13 | for all prosthetic devices and any other items recognized as | ||||||
14 | medical equipment and supplies reimbursable under this Article | ||||||
15 | and shall update such list on a quarterly basis, except that | ||||||
16 | the acquisition costs of all prescription drugs shall be | ||||||
17 | updated no less frequently than every 30 days as required by | ||||||
18 | Section 5-5.12. | ||||||
19 | Notwithstanding any other law to the contrary, the | ||||||
20 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
21 | (the effective date of Public Act 98-104), establish | ||||||
22 | procedures to permit skilled care facilities licensed under | ||||||
23 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
24 | reimbursement purposes. Following development of these | ||||||
25 | procedures, the Department shall, by July 1, 2016, test the | ||||||
26 | viability of the new system and implement any necessary |
| |||||||
| |||||||
1 | operational or structural changes to its information | ||||||
2 | technology platforms in order to allow for the direct | ||||||
3 | acceptance and payment of nursing home claims. | ||||||
4 | Notwithstanding any other law to the contrary, the | ||||||
5 | Illinois Department shall, within 365 days after August 15, | ||||||
6 | 2014 (the effective date of Public Act 98-963), establish | ||||||
7 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
8 | Community Care Act and MC/DD facilities licensed under the | ||||||
9 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
10 | purposes. Following development of these procedures, the | ||||||
11 | Department shall have an additional 365 days to test the | ||||||
12 | viability of the new system and to ensure that any necessary | ||||||
13 | operational or structural changes to its information | ||||||
14 | technology platforms are implemented. | ||||||
15 | The Illinois Department shall require all dispensers of | ||||||
16 | medical services, other than an individual practitioner or | ||||||
17 | group of practitioners, desiring to participate in the Medical | ||||||
18 | Assistance program established under this Article to disclose | ||||||
19 | all financial, beneficial, ownership, equity, surety or other | ||||||
20 | interests in any and all firms, corporations, partnerships, | ||||||
21 | associations, business enterprises, joint ventures, agencies, | ||||||
22 | institutions or other legal entities providing any form of | ||||||
23 | health care services in this State under this Article. | ||||||
24 | The Illinois Department may require that all dispensers of | ||||||
25 | medical services desiring to participate in the medical | ||||||
26 | assistance program established under this Article disclose, |
| |||||||
| |||||||
1 | under such terms and conditions as the Illinois Department may | ||||||
2 | by rule establish, all inquiries from clients and attorneys | ||||||
3 | regarding medical bills paid by the Illinois Department, which | ||||||
4 | inquiries could indicate potential existence of claims or | ||||||
5 | liens for the Illinois Department. | ||||||
6 | Enrollment of a vendor shall be subject to a provisional | ||||||
7 | period and shall be conditional for one year. During the | ||||||
8 | period of conditional enrollment, the Department may terminate | ||||||
9 | the vendor's eligibility to participate in, or may disenroll | ||||||
10 | the vendor from, the medical assistance program without cause. | ||||||
11 | Unless otherwise specified, such termination of eligibility or | ||||||
12 | disenrollment is not subject to the Department's hearing | ||||||
13 | process. However, a disenrolled vendor may reapply without | ||||||
14 | penalty. | ||||||
15 | The Department has the discretion to limit the conditional | ||||||
16 | enrollment period for vendors based upon the category of risk | ||||||
17 | of the vendor. | ||||||
18 | Prior to enrollment and during the conditional enrollment | ||||||
19 | period in the medical assistance program, all vendors shall be | ||||||
20 | subject to enhanced oversight, screening, and review based on | ||||||
21 | the risk of fraud, waste, and abuse that is posed by the | ||||||
22 | category of risk of the vendor. The Illinois Department shall | ||||||
23 | establish the procedures for oversight, screening, and review, | ||||||
24 | which may include, but need not be limited to: criminal and | ||||||
25 | financial background checks; fingerprinting; license, | ||||||
26 | certification, and authorization verifications; unscheduled or |
| |||||||
| |||||||
1 | unannounced site visits; database checks; prepayment audit | ||||||
2 | reviews; audits; payment caps; payment suspensions; and other | ||||||
3 | screening as required by federal or State law. | ||||||
4 | The Department shall define or specify the following: (i) | ||||||
5 | by provider notice, the "category of risk of the vendor" for | ||||||
6 | each type of vendor, which shall take into account the level of | ||||||
7 | screening applicable to a particular category of vendor under | ||||||
8 | federal law and regulations; (ii) by rule or provider notice, | ||||||
9 | the maximum length of the conditional enrollment period for | ||||||
10 | each category of risk of the vendor; and (iii) by rule, the | ||||||
11 | hearing rights, if any, afforded to a vendor in each category | ||||||
12 | of risk of the vendor that is terminated or disenrolled during | ||||||
13 | the conditional enrollment period. | ||||||
14 | To be eligible for payment consideration, a vendor's | ||||||
15 | payment claim or bill, either as an initial claim or as a | ||||||
16 | resubmitted claim following prior rejection, must be received | ||||||
17 | by the Illinois Department, or its fiscal intermediary, no | ||||||
18 | later than 180 days after the latest date on the claim on which | ||||||
19 | medical goods or services were provided, with the following | ||||||
20 | exceptions: | ||||||
21 | (1) In the case of a provider whose enrollment is in | ||||||
22 | process by the Illinois Department, the 180-day period | ||||||
23 | shall not begin until the date on the written notice from | ||||||
24 | the Illinois Department that the provider enrollment is | ||||||
25 | complete. | ||||||
26 | (2) In the case of errors attributable to the Illinois |
| |||||||
| |||||||
1 | Department or any of its claims processing intermediaries | ||||||
2 | which result in an inability to receive, process, or | ||||||
3 | adjudicate a claim, the 180-day period shall not begin | ||||||
4 | until the provider has been notified of the error. | ||||||
5 | (3) In the case of a provider for whom the Illinois | ||||||
6 | Department initiates the monthly billing process. | ||||||
7 | (4) In the case of a provider operated by a unit of | ||||||
8 | local government with a population exceeding 3,000,000 | ||||||
9 | when local government funds finance federal participation | ||||||
10 | for claims payments. | ||||||
11 | For claims for services rendered during a period for which | ||||||
12 | a recipient received retroactive eligibility, claims must be | ||||||
13 | filed within 180 days after the Department determines the | ||||||
14 | applicant is eligible. For claims for which the Illinois | ||||||
15 | Department is not the primary payer, claims must be submitted | ||||||
16 | to the Illinois Department within 180 days after the final | ||||||
17 | adjudication by the primary payer. | ||||||
18 | In the case of long term care facilities, within 120 | ||||||
19 | calendar days of receipt by the facility of required | ||||||
20 | prescreening information, new admissions with associated | ||||||
21 | admission documents shall be submitted through the Medical | ||||||
22 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
23 | Eligibility Verification (REV) System or shall be submitted | ||||||
24 | directly to the Department of Human Services using required | ||||||
25 | admission forms. Effective September 1, 2014, admission | ||||||
26 | documents, including all prescreening information, must be |
| |||||||
| |||||||
1 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
2 | to an accepted transaction shall be retained by a facility to | ||||||
3 | verify timely submittal. Once an admission transaction has | ||||||
4 | been completed, all resubmitted claims following prior | ||||||
5 | rejection are subject to receipt no later than 180 days after | ||||||
6 | the admission transaction has been completed. | ||||||
7 | Claims that are not submitted and received in compliance | ||||||
8 | with the foregoing requirements shall not be eligible for | ||||||
9 | payment under the medical assistance program, and the State | ||||||
10 | shall have no liability for payment of those claims. | ||||||
11 | To the extent consistent with applicable information and | ||||||
12 | privacy, security, and disclosure laws, State and federal | ||||||
13 | agencies and departments shall provide the Illinois Department | ||||||
14 | access to confidential and other information and data | ||||||
15 | necessary to perform eligibility and payment verifications and | ||||||
16 | other Illinois Department functions. This includes, but is not | ||||||
17 | limited to: information pertaining to licensure; | ||||||
18 | certification; earnings; immigration status; citizenship; wage | ||||||
19 | reporting; unearned and earned income; pension income; | ||||||
20 | employment; supplemental security income; social security | ||||||
21 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
22 | National Practitioner Data Bank (NPDB); program and agency | ||||||
23 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
24 | corporate information; and death records. | ||||||
25 | The Illinois Department shall enter into agreements with | ||||||
26 | State agencies and departments, and is authorized to enter |
| |||||||
| |||||||
1 | into agreements with federal agencies and departments, under | ||||||
2 | which such agencies and departments shall share data necessary | ||||||
3 | for medical assistance program integrity functions and | ||||||
4 | oversight. The Illinois Department shall develop, in | ||||||
5 | cooperation with other State departments and agencies, and in | ||||||
6 | compliance with applicable federal laws and regulations, | ||||||
7 | appropriate and effective methods to share such data. At a | ||||||
8 | minimum, and to the extent necessary to provide data sharing, | ||||||
9 | the Illinois Department shall enter into agreements with State | ||||||
10 | agencies and departments, and is authorized to enter into | ||||||
11 | agreements with federal agencies and departments, including, | ||||||
12 | but not limited to: the Secretary of State; the Department of | ||||||
13 | Revenue; the Department of Public Health; the Department of | ||||||
14 | Human Services; and the Department of Financial and | ||||||
15 | Professional Regulation. | ||||||
16 | Beginning in fiscal year 2013, the Illinois Department | ||||||
17 | shall set forth a request for information to identify the | ||||||
18 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
19 | claims system with the goals of streamlining claims processing | ||||||
20 | and provider reimbursement, reducing the number of pending or | ||||||
21 | rejected claims, and helping to ensure a more transparent | ||||||
22 | adjudication process through the utilization of: (i) provider | ||||||
23 | data verification and provider screening technology; and (ii) | ||||||
24 | clinical code editing; and (iii) pre-pay, pre-adjudicated , or | ||||||
25 | post-adjudicated predictive modeling with an integrated case | ||||||
26 | management system with link analysis. Such a request for |
| |||||||
| |||||||
1 | information shall not be considered as a request for proposal | ||||||
2 | or as an obligation on the part of the Illinois Department to | ||||||
3 | take any action or acquire any products or services. | ||||||
4 | The Illinois Department shall establish policies, | ||||||
5 | procedures, standards and criteria by rule for the | ||||||
6 | acquisition, repair and replacement of orthotic and prosthetic | ||||||
7 | devices and durable medical equipment. Such rules shall | ||||||
8 | provide, but not be limited to, the following services: (1) | ||||||
9 | immediate repair or replacement of such devices by recipients; | ||||||
10 | and (2) rental, lease, purchase or lease-purchase of durable | ||||||
11 | medical equipment in a cost-effective manner, taking into | ||||||
12 | consideration the recipient's medical prognosis, the extent of | ||||||
13 | the recipient's needs, and the requirements and costs for | ||||||
14 | maintaining such equipment. Subject to prior approval, such | ||||||
15 | rules shall enable a recipient to temporarily acquire and use | ||||||
16 | alternative or substitute devices or equipment pending repairs | ||||||
17 | or replacements of any device or equipment previously | ||||||
18 | authorized for such recipient by the Department. | ||||||
19 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
20 | the Department may, by rule, exempt certain replacement | ||||||
21 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
22 | wheelchair parts, wheelchair accessories, and related seating | ||||||
23 | and positioning items, determine the wholesale price by | ||||||
24 | methods other than actual acquisition costs. | ||||||
25 | The Department shall require, by rule, all providers of | ||||||
26 | durable medical equipment to be accredited by an accreditation |
| |||||||
| |||||||
1 | organization approved by the federal Centers for Medicare and | ||||||
2 | Medicaid Services and recognized by the Department in order to | ||||||
3 | bill the Department for providing durable medical equipment to | ||||||
4 | recipients. No later than 15 months after the effective date | ||||||
5 | of the rule adopted pursuant to this paragraph, all providers | ||||||
6 | must meet the accreditation requirement. | ||||||
7 | In order to promote environmental responsibility, meet the | ||||||
8 | needs of recipients and enrollees, and achieve significant | ||||||
9 | cost savings, the Department, or a managed care organization | ||||||
10 | under contract with the Department, may provide recipients or | ||||||
11 | managed care enrollees who have a prescription or Certificate | ||||||
12 | of Medical Necessity access to refurbished durable medical | ||||||
13 | equipment under this Section (excluding prosthetic and | ||||||
14 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
15 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
16 | products and associated services) through the State's | ||||||
17 | assistive technology program's reutilization program, using | ||||||
18 | staff with the Assistive Technology Professional (ATP) | ||||||
19 | Certification if the refurbished durable medical equipment: | ||||||
20 | (i) is available; (ii) is less expensive, including shipping | ||||||
21 | costs, than new durable medical equipment of the same type; | ||||||
22 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
23 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
24 | federal Food and Drug Administration regulations and guidance | ||||||
25 | governing the reprocessing of medical devices in health care | ||||||
26 | settings; and (v) equally meets the needs of the recipient or |
| |||||||
| |||||||
1 | enrollee. The reutilization program shall confirm that the | ||||||
2 | recipient or enrollee is not already in receipt of the same or | ||||||
3 | similar equipment from another service provider, and that the | ||||||
4 | refurbished durable medical equipment equally meets the needs | ||||||
5 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
6 | be construed to limit recipient or enrollee choice to obtain | ||||||
7 | new durable medical equipment or place any additional prior | ||||||
8 | authorization conditions on enrollees of managed care | ||||||
9 | organizations. | ||||||
10 | The Department shall execute, relative to the nursing home | ||||||
11 | prescreening project, written inter-agency agreements with the | ||||||
12 | Department of Human Services and the Department on Aging, to | ||||||
13 | effect the following: (i) intake procedures and common | ||||||
14 | eligibility criteria for those persons who are receiving | ||||||
15 | non-institutional services; and (ii) the establishment and | ||||||
16 | development of non-institutional services in areas of the | ||||||
17 | State where they are not currently available or are | ||||||
18 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
19 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
20 | increase in the determination of need (DON) scores from 29 to | ||||||
21 | 37 for applicants for institutional and home and | ||||||
22 | community-based long term care; if and only if federal | ||||||
23 | approval is not granted, the Department may, in conjunction | ||||||
24 | with other affected agencies, implement utilization controls | ||||||
25 | or changes in benefit packages to effectuate a similar savings | ||||||
26 | amount for this population; and (iv) no later than July 1, |
| |||||||
| |||||||
1 | 2013, minimum level of care eligibility criteria for | ||||||
2 | institutional and home and community-based long term care; and | ||||||
3 | (v) no later than October 1, 2013, establish procedures to | ||||||
4 | permit long term care providers access to eligibility scores | ||||||
5 | for individuals with an admission date who are seeking or | ||||||
6 | receiving services from the long term care provider. In order | ||||||
7 | to select the minimum level of care eligibility criteria, the | ||||||
8 | Governor shall establish a workgroup that includes affected | ||||||
9 | agency representatives and stakeholders representing the | ||||||
10 | institutional and home and community-based long term care | ||||||
11 | interests. This Section shall not restrict the Department from | ||||||
12 | implementing lower level of care eligibility criteria for | ||||||
13 | community-based services in circumstances where federal | ||||||
14 | approval has been granted. | ||||||
15 | The Illinois Department shall develop and operate, in | ||||||
16 | cooperation with other State Departments and agencies and in | ||||||
17 | compliance with applicable federal laws and regulations, | ||||||
18 | appropriate and effective systems of health care evaluation | ||||||
19 | and programs for monitoring of utilization of health care | ||||||
20 | services and facilities, as it affects persons eligible for | ||||||
21 | medical assistance under this Code. | ||||||
22 | The Illinois Department shall report annually to the | ||||||
23 | General Assembly, no later than the second Friday in April of | ||||||
24 | 1979 and each year thereafter, in regard to: | ||||||
25 | (a) actual statistics and trends in utilization of | ||||||
26 | medical services by public aid recipients; |
| |||||||
| |||||||
1 | (b) actual statistics and trends in the provision of | ||||||
2 | the various medical services by medical vendors; | ||||||
3 | (c) current rate structures and proposed changes in | ||||||
4 | those rate structures for the various medical vendors; and | ||||||
5 | (d) efforts at utilization review and control by the | ||||||
6 | Illinois Department. | ||||||
7 | The period covered by each report shall be the 3 years | ||||||
8 | ending on the June 30 prior to the report. The report shall | ||||||
9 | include suggested legislation for consideration by the General | ||||||
10 | Assembly. The requirement for reporting to the General | ||||||
11 | Assembly shall be satisfied by filing copies of the report as | ||||||
12 | required by Section 3.1 of the General Assembly Organization | ||||||
13 | Act, and filing such additional copies with the State | ||||||
14 | Government Report Distribution Center for the General Assembly | ||||||
15 | as is required under paragraph (t) of Section 7 of the State | ||||||
16 | Library Act. | ||||||
17 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
18 | any, is conditioned on the rules being adopted in accordance | ||||||
19 | with all provisions of the Illinois Administrative Procedure | ||||||
20 | Act and all rules and procedures of the Joint Committee on | ||||||
21 | Administrative Rules; any purported rule not so adopted, for | ||||||
22 | whatever reason, is unauthorized. | ||||||
23 | On and after July 1, 2012, the Department shall reduce any | ||||||
24 | rate of reimbursement for services or other payments or alter | ||||||
25 | any methodologies authorized by this Code to reduce any rate | ||||||
26 | of reimbursement for services or other payments in accordance |
| |||||||
| |||||||
1 | with Section 5-5e. | ||||||
2 | Because kidney transplantation can be an appropriate, | ||||||
3 | cost-effective alternative to renal dialysis when medically | ||||||
4 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
5 | of this Code, beginning October 1, 2014, the Department shall | ||||||
6 | cover kidney transplantation for noncitizens with end-stage | ||||||
7 | renal disease who are not eligible for comprehensive medical | ||||||
8 | benefits, who meet the residency requirements of Section 5-3 | ||||||
9 | of this Code, and who would otherwise meet the financial | ||||||
10 | requirements of the appropriate class of eligible persons | ||||||
11 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
12 | kidney transplantation, such person must be receiving | ||||||
13 | emergency renal dialysis services covered by the Department. | ||||||
14 | Providers under this Section shall be prior approved and | ||||||
15 | certified by the Department to perform kidney transplantation | ||||||
16 | and the services under this Section shall be limited to | ||||||
17 | services associated with kidney transplantation. | ||||||
18 | Notwithstanding any other provision of this Code to the | ||||||
19 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
20 | medication assisted treatment prescribed for the treatment of | ||||||
21 | alcohol dependence or treatment of opioid dependence shall be | ||||||
22 | covered under both fee-for-service fee for service and managed | ||||||
23 | care medical assistance programs for persons who are otherwise | ||||||
24 | eligible for medical assistance under this Article and shall | ||||||
25 | not be subject to any (1) utilization control, other than | ||||||
26 | those established under the American Society of Addiction |
| |||||||
| |||||||
1 | Medicine patient placement criteria, (2) prior authorization | ||||||
2 | mandate, or (3) lifetime restriction limit mandate. | ||||||
3 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
4 | for the treatment of an opioid overdose, including the | ||||||
5 | medication product, administration devices, and any pharmacy | ||||||
6 | fees or hospital fees related to the dispensing, distribution, | ||||||
7 | and administration of the opioid antagonist, shall be covered | ||||||
8 | under the medical assistance program for persons who are | ||||||
9 | otherwise eligible for medical assistance under this Article. | ||||||
10 | As used in this Section, "opioid antagonist" means a drug that | ||||||
11 | binds to opioid receptors and blocks or inhibits the effect of | ||||||
12 | opioids acting on those receptors, including, but not limited | ||||||
13 | to, naloxone hydrochloride or any other similarly acting drug | ||||||
14 | approved by the U.S. Food and Drug Administration. The | ||||||
15 | Department shall not impose a copayment on the coverage | ||||||
16 | provided for naloxone hydrochloride under the medical | ||||||
17 | assistance program. | ||||||
18 | Upon federal approval, the Department shall provide | ||||||
19 | coverage and reimbursement for all drugs that are approved for | ||||||
20 | marketing by the federal Food and Drug Administration and that | ||||||
21 | are recommended by the federal Public Health Service or the | ||||||
22 | United States Centers for Disease Control and Prevention for | ||||||
23 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
24 | services, including, but not limited to, HIV and sexually | ||||||
25 | transmitted infection screening, treatment for sexually | ||||||
26 | transmitted infections, medical monitoring, assorted labs, and |
| |||||||
| |||||||
1 | counseling to reduce the likelihood of HIV infection among | ||||||
2 | individuals who are not infected with HIV but who are at high | ||||||
3 | risk of HIV infection. | ||||||
4 | A federally qualified health center, as defined in Section | ||||||
5 | 1905(l)(2)(B) of the federal Social Security Act, shall be | ||||||
6 | reimbursed by the Department in accordance with the federally | ||||||
7 | qualified health center's encounter rate for services provided | ||||||
8 | to medical assistance recipients that are performed by a | ||||||
9 | dental hygienist, as defined under the Illinois Dental | ||||||
10 | Practice Act, working under the general supervision of a | ||||||
11 | dentist and employed by a federally qualified health center. | ||||||
12 | Within 90 days after October 8, 2021 (the effective date | ||||||
13 | of Public Act 102-665), the Department shall seek federal | ||||||
14 | approval of a State Plan amendment to expand coverage for | ||||||
15 | family planning services that includes presumptive eligibility | ||||||
16 | to individuals whose income is at or below 208% of the federal | ||||||
17 | poverty level. Coverage under this Section shall be effective | ||||||
18 | beginning no later than December 1, 2022. | ||||||
19 | Subject to approval by the federal Centers for Medicare | ||||||
20 | and Medicaid Services of a Title XIX State Plan amendment | ||||||
21 | electing the Program of All-Inclusive Care for the Elderly | ||||||
22 | (PACE) as a State Medicaid option, as provided for by Subtitle | ||||||
23 | I (commencing with Section 4801) of Title IV of the Balanced | ||||||
24 | Budget Act of 1997 (Public Law 105-33) and Part 460 | ||||||
25 | (commencing with Section 460.2) of Subchapter E of Title 42 of | ||||||
26 | the Code of Federal Regulations, PACE program services shall |
| |||||||
| |||||||
1 | become a covered benefit of the medical assistance program, | ||||||
2 | subject to criteria established in accordance with all | ||||||
3 | applicable laws. | ||||||
4 | Notwithstanding any other provision of this Code, | ||||||
5 | community-based pediatric palliative care from a trained | ||||||
6 | interdisciplinary team shall be covered under the medical | ||||||
7 | assistance program as provided in Section 15 of the Pediatric | ||||||
8 | Palliative Care Act. | ||||||
9 | Notwithstanding any other provision of this Code, within | ||||||
10 | 12 months after June 2, 2022 (the effective date of Public Act | ||||||
11 | 102-1037) and subject to federal approval, acupuncture | ||||||
12 | services performed by an acupuncturist licensed under the | ||||||
13 | Acupuncture Practice Act who is acting within the scope of his | ||||||
14 | or her license shall be covered under the medical assistance | ||||||
15 | program. The Department shall apply for any federal waiver or | ||||||
16 | State Plan amendment, if required, to implement this | ||||||
17 | paragraph. The Department may adopt any rules, including | ||||||
18 | standards and criteria, necessary to implement this paragraph. | ||||||
19 | Notwithstanding any other provision of this Code, the | ||||||
20 | medical assistance program shall, subject to appropriation and | ||||||
21 | federal approval, reimburse hospitals for costs associated | ||||||
22 | with a newborn screening test for the presence of | ||||||
23 | metachromatic leukodystrophy, as required under the Newborn | ||||||
24 | Metabolic Screening Act, at a rate not less than the fee | ||||||
25 | charged by the Department of Public Health. The Department | ||||||
26 | shall seek federal approval before the implementation of the |
| |||||||
| |||||||
1 | newborn screening test fees by the Department of Public | ||||||
2 | Health. | ||||||
3 | Notwithstanding any other provision of this Code, | ||||||
4 | beginning on January 1, 2024, subject to federal approval, | ||||||
5 | cognitive assessment and care planning services provided to a | ||||||
6 | person who experiences signs or symptoms of cognitive | ||||||
7 | impairment, as defined by the Diagnostic and Statistical | ||||||
8 | Manual of Mental Disorders, Fifth Edition, shall be covered | ||||||
9 | under the medical assistance program for persons who are | ||||||
10 | otherwise eligible for medical assistance under this Article. | ||||||
11 | Notwithstanding any other provision of this Code, | ||||||
12 | medically necessary reconstructive services that are intended | ||||||
13 | to restore physical appearance shall be covered under the | ||||||
14 | medical assistance program for persons who are otherwise | ||||||
15 | eligible for medical assistance under this Article. As used in | ||||||
16 | this paragraph, "reconstructive services" means treatments | ||||||
17 | performed on structures of the body damaged by trauma to | ||||||
18 | restore physical appearance. | ||||||
19 | (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; | ||||||
20 | 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article | ||||||
21 | 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, | ||||||
22 | eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; | ||||||
23 | 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. | ||||||
24 | 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; | ||||||
25 | 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. | ||||||
26 | 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; |
| |||||||
| |||||||
1 | 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. | ||||||
2 | 1-1-24; revised 12-15-23.) | ||||||
3 | ARTICLE 10. | ||||||
4 | Section 10-5. The Illinois Public Aid Code is amended by | ||||||
5 | adding Section 5-5.05h as follows: | ||||||
6 | (305 ILCS 5/5-5.05h new) | ||||||
7 | Sec. 5-5.05h. Reimbursement rates for psychiatric | ||||||
8 | evaluations and medication monitoring. Subject to federal | ||||||
9 | approval, for dates of service on and after January 1, 2025, | ||||||
10 | the Department shall make a one-time adjustment to the add-on | ||||||
11 | rates for services delivered by physicians who are | ||||||
12 | board-certified in psychiatry and advanced practice registered | ||||||
13 | nurses who hold a current certification in psychiatric and | ||||||
14 | mental health nursing. The one-time adjustment shall increase | ||||||
15 | the add-on rates so that the sum of the Department's base per | ||||||
16 | service unit rate plus the rate add-on is no less than $264.42 | ||||||
17 | per hour adjusted for time and intensity as determined by the | ||||||
18 | work relative value units in the 2024 national Medicare | ||||||
19 | physician fee schedule, indexed to 60 minutes of individual | ||||||
20 | psychotherapy. | ||||||
21 | ARTICLE 15. |
| |||||||
| |||||||
1 | Section 15-5. The Illinois Public Aid Code is amended by | ||||||
2 | changing Section 5-5.01a as follows: | ||||||
3 | (305 ILCS 5/5-5.01a) | ||||||
4 | Sec. 5-5.01a. Supportive living facilities program. | ||||||
5 | (a) The Department shall establish and provide oversight | ||||||
6 | for a program of supportive living facilities that seek to | ||||||
7 | promote resident independence, dignity, respect, and | ||||||
8 | well-being in the most cost-effective manner. | ||||||
9 | A supportive living facility is (i) a free-standing | ||||||
10 | facility or (ii) a distinct physical and operational entity | ||||||
11 | within a mixed-use building that meets the criteria | ||||||
12 | established in subsection (d). A supportive living facility | ||||||
13 | integrates housing with health, personal care, and supportive | ||||||
14 | services and is a designated setting that offers residents | ||||||
15 | their own separate, private, and distinct living units. | ||||||
16 | Sites for the operation of the program shall be selected | ||||||
17 | by the Department based upon criteria that may include the | ||||||
18 | need for services in a geographic area, the availability of | ||||||
19 | funding, and the site's ability to meet the standards. | ||||||
20 | (b) Beginning July 1, 2014, subject to federal approval, | ||||||
21 | the Medicaid rates for supportive living facilities shall be | ||||||
22 | equal to the supportive living facility Medicaid rate | ||||||
23 | effective on June 30, 2014 increased by 8.85%. Once the | ||||||
24 | assessment imposed at Article V-G of this Code is determined | ||||||
25 | to be a permissible tax under Title XIX of the Social Security |
| |||||||
| |||||||
1 | Act, the Department shall increase the Medicaid rates for | ||||||
2 | supportive living facilities effective on July 1, 2014 by | ||||||
3 | 9.09%. The Department shall apply this increase retroactively | ||||||
4 | to coincide with the imposition of the assessment in Article | ||||||
5 | V-G of this Code in accordance with the approval for federal | ||||||
6 | financial participation by the Centers for Medicare and | ||||||
7 | Medicaid Services. | ||||||
8 | The Medicaid rates for supportive living facilities | ||||||
9 | effective on July 1, 2017 must be equal to the rates in effect | ||||||
10 | for supportive living facilities on June 30, 2017 increased by | ||||||
11 | 2.8%. | ||||||
12 | The Medicaid rates for supportive living facilities | ||||||
13 | effective on July 1, 2018 must be equal to the rates in effect | ||||||
14 | for supportive living facilities on June 30, 2018. | ||||||
15 | Subject to federal approval, the Medicaid rates for | ||||||
16 | supportive living services on and after July 1, 2019 must be at | ||||||
17 | least 54.3% of the average total nursing facility services per | ||||||
18 | diem for the geographic areas defined by the Department while | ||||||
19 | maintaining the rate differential for dementia care and must | ||||||
20 | be updated whenever the total nursing facility service per | ||||||
21 | diems are updated. Beginning July 1, 2022, upon the | ||||||
22 | implementation of the Patient Driven Payment Model, Medicaid | ||||||
23 | rates for supportive living services must be at least 54.3% of | ||||||
24 | the average total nursing services per diem rate for the | ||||||
25 | geographic areas. For purposes of this provision, the average | ||||||
26 | total nursing services per diem rate shall include all add-ons |
| |||||||
| |||||||
1 | for nursing facilities for the geographic area provided for in | ||||||
2 | Section 5-5.2. The rate differential for dementia care must be | ||||||
3 | maintained in these rates and the rates shall be updated | ||||||
4 | whenever nursing facility per diem rates are updated. | ||||||
5 | Subject to federal approval, beginning January 1, 2024, | ||||||
6 | the dementia care rate for supportive living services must be | ||||||
7 | no less than the non-dementia care supportive living services | ||||||
8 | rate multiplied by 1.5. | ||||||
9 | (c) The Department may adopt rules to implement this | ||||||
10 | Section. Rules that establish or modify the services, | ||||||
11 | standards, and conditions for participation in the program | ||||||
12 | shall be adopted by the Department in consultation with the | ||||||
13 | Department on Aging, the Department of Rehabilitation | ||||||
14 | Services, and the Department of Mental Health and | ||||||
15 | Developmental Disabilities (or their successor agencies). | ||||||
16 | (d) Subject to federal approval by the Centers for | ||||||
17 | Medicare and Medicaid Services, the Department shall accept | ||||||
18 | for consideration of certification under the program any | ||||||
19 | application for a site or building where distinct parts of the | ||||||
20 | site or building are designated for purposes other than the | ||||||
21 | provision of supportive living services, but only if: | ||||||
22 | (1) those distinct parts of the site or building are | ||||||
23 | not designated for the purpose of providing assisted | ||||||
24 | living services as required under the Assisted Living and | ||||||
25 | Shared Housing Act; | ||||||
26 | (2) those distinct parts of the site or building are |
| |||||||
| |||||||
1 | completely separate from the part of the building used for | ||||||
2 | the provision of supportive living program services, | ||||||
3 | including separate entrances; | ||||||
4 | (3) those distinct parts of the site or building do | ||||||
5 | not share any common spaces with the part of the building | ||||||
6 | used for the provision of supportive living program | ||||||
7 | services; and | ||||||
8 | (4) those distinct parts of the site or building do | ||||||
9 | not share staffing with the part of the building used for | ||||||
10 | the provision of supportive living program services. | ||||||
11 | (e) Facilities or distinct parts of facilities which are | ||||||
12 | selected as supportive living facilities and are in good | ||||||
13 | standing with the Department's rules are exempt from the | ||||||
14 | provisions of the Nursing Home Care Act and the Illinois | ||||||
15 | Health Facilities Planning Act. | ||||||
16 | (f) Section 9817 of the American Rescue Plan Act of 2021 | ||||||
17 | (Public Law 117-2) authorizes a 10% enhanced federal medical | ||||||
18 | assistance percentage for supportive living services for a | ||||||
19 | 12-month period from April 1, 2021 through March 31, 2022. | ||||||
20 | Subject to federal approval, including the approval of any | ||||||
21 | necessary waiver amendments or other federally required | ||||||
22 | documents or assurances, for a 12-month period the Department | ||||||
23 | must pay a supplemental $26 per diem rate to all supportive | ||||||
24 | living facilities with the additional federal financial | ||||||
25 | participation funds that result from the enhanced federal | ||||||
26 | medical assistance percentage from April 1, 2021 through March |
| |||||||
| |||||||
1 | 31, 2022. The Department may issue parameters around how the | ||||||
2 | supplemental payment should be spent, including quality | ||||||
3 | improvement activities. The Department may alter the form, | ||||||
4 | methods, or timeframes concerning the supplemental per diem | ||||||
5 | rate to comply with any subsequent changes to federal law, | ||||||
6 | changes made by guidance issued by the federal Centers for | ||||||
7 | Medicare and Medicaid Services, or other changes necessary to | ||||||
8 | receive the enhanced federal medical assistance percentage. | ||||||
9 | (g) All applications for the expansion of supportive | ||||||
10 | living dementia care settings involving sites not approved by | ||||||
11 | the Department on January 1, 2024 ( the effective date of | ||||||
12 | Public Act 103-102) this amendatory Act of the 103rd General | ||||||
13 | Assembly may allow new elderly non-dementia units in addition | ||||||
14 | to new dementia care units. The Department may approve such | ||||||
15 | applications only if the application has: (1) no more than one | ||||||
16 | non-dementia care unit for each dementia care unit and (2) the | ||||||
17 | site is not located within 4 miles of an existing supportive | ||||||
18 | living program site in Cook County (including the City of | ||||||
19 | Chicago), not located within 12 miles of an existing | ||||||
20 | supportive living program site in DuPage County, Kane County, | ||||||
21 | Lake County, McHenry County, or Will County, or not located | ||||||
22 | within 25 miles of an existing supportive living program site | ||||||
23 | in any other county. | ||||||
24 | (h) Beginning January 1, 2025, subject to federal | ||||||
25 | approval, for a person who is a resident of a supportive living | ||||||
26 | facility under this Section, the monthly personal needs |
| |||||||
| |||||||
1 | allowance shall be $120 per month. | ||||||
2 | (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; | ||||||
3 | 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, | ||||||
4 | Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.) | ||||||
5 | ARTICLE 20. | ||||||
6 | Section 20-5. The Birth Center Licensing Act is amended by | ||||||
7 | changing Section 40 as follows: | ||||||
8 | (210 ILCS 170/40) | ||||||
9 | Sec. 40. Reimbursement requirements. | ||||||
10 | (a) A birth center shall seek certification under Titles | ||||||
11 | XVIII and XIX of the federal Social Security Act. | ||||||
12 | (b) Services provided to individuals eligible for medical | ||||||
13 | assistance shall be covered in accordance with Article V of | ||||||
14 | the Illinois Public Aid Code and reimbursement rates shall be | ||||||
15 | set by the Department of Healthcare and Family Services. | ||||||
16 | Reimbursement rates set by the Department of Healthcare and | ||||||
17 | Family Services should be based on all types of medically | ||||||
18 | necessary covered services provided to both the birthing | ||||||
19 | person and the baby, including: | ||||||
20 | (1) a professional fee for both the birthing person | ||||||
21 | and baby; | ||||||
22 | (2) a facility fee for the birthing person that is no | ||||||
23 | less than 75% of the statewide average facility payment |
| |||||||
| |||||||
1 | rate made to a hospital for an uncomplicated vaginal | ||||||
2 | birth; | ||||||
3 | (3) a facility fee for the baby that is no less than | ||||||
4 | 75% of the statewide average facility payment rate made to | ||||||
5 | a hospital for a normal baby; and | ||||||
6 | (4) additional fees for other services, medications, | ||||||
7 | laboratory tests, and supplies provided. | ||||||
8 | (c) A birth center shall provide charitable care | ||||||
9 | consistent with that provided by comparable health care | ||||||
10 | providers in the geographic area. | ||||||
11 | (d) A birth center may not discriminate against any | ||||||
12 | patient requiring treatment because of the source of payment | ||||||
13 | for services, including Medicare and Medicaid recipients. | ||||||
14 | (Source: P.A. 102-518, eff. 8-20-21.) | ||||||
15 | Section 20-10. The Illinois Public Aid Code is amended by | ||||||
16 | adding Section 5-18.3 as follows: | ||||||
17 | (305 ILCS 5/5-18.3 new) | ||||||
18 | Sec. 5-18.3. Birth center; facility fee. | ||||||
19 | (a) Reimbursement for services covered under this Article | ||||||
20 | and provided at a birth center as defined in Section 5 of the | ||||||
21 | Birth Center Licensing Act shall include: | ||||||
22 | (1) Beginning January 1, 2025, subject to federal | ||||||
23 | approval, a facility fee for the birthing person and baby | ||||||
24 | that is no less than 80% of the statewide average facility |
| |||||||
| |||||||
1 | payment rate made to a hospital for an uncomplicated | ||||||
2 | vaginal birth. The facility fee shall include medications, | ||||||
3 | laboratory tests, and supplies provided. | ||||||
4 | (2) Beginning January 1, 2025, no less than 80% of the | ||||||
5 | Department fee schedule rate for professional services for | ||||||
6 | the birthing person and baby covered under this Article | ||||||
7 | that are reimbursable separate from the facility fee and | ||||||
8 | provided within the scope of licensure or certification of | ||||||
9 | both the practitioner and birth center. | ||||||
10 | (b) The Department shall submit any necessary application | ||||||
11 | to the federal Centers for Medicare and Medicaid Services for | ||||||
12 | a waiver or State Plan amendment to implement the requirements | ||||||
13 | of this Section. | ||||||
14 | ARTICLE 30. | ||||||
15 | Section 30-5. The Illinois Public Aid Code is amended by | ||||||
16 | changing Sections 5H-1 and 5H-3 as follows: | ||||||
17 | (305 ILCS 5/5H-1) | ||||||
18 | Sec. 5H-1. Definitions. As used in this Article: | ||||||
19 | "Base year" means the 12-month period from January 1, 2023 | ||||||
20 | 2018 to December 31, 2023 2018 . | ||||||
21 | "Department" means the Department of Healthcare and Family | ||||||
22 | Services. | ||||||
23 | "Federal employee health benefit" means the program of |
| |||||||
| |||||||
1 | health benefits plans, as defined in 5 U.S.C. 8901, available | ||||||
2 | to federal employees under 5 U.S.C. 8901 to 8914. | ||||||
3 | "Fund" means the Healthcare Provider Relief Fund. | ||||||
4 | "Managed care organization" means an entity operating | ||||||
5 | under a certificate of authority issued pursuant to the Health | ||||||
6 | Maintenance Organization Act or as a Managed Care Community | ||||||
7 | Network pursuant to Section 5-11 of this Code. | ||||||
8 | "Medicaid managed care organization" means a managed care | ||||||
9 | organization under contract with the Department to provide | ||||||
10 | services to recipients of benefits in the medical assistance | ||||||
11 | program pursuant to Article V of this Code, the Children's | ||||||
12 | Health Insurance Program Act, or the Covering ALL KIDS Health | ||||||
13 | Insurance Act. It does not include contracts the same entity | ||||||
14 | or an affiliated entity has for other business. | ||||||
15 | "Medicare" means the federal Medicare program established | ||||||
16 | under Title XVIII of the federal Social Security Act. | ||||||
17 | "Member months" means the aggregate total number of months | ||||||
18 | all individuals are enrolled for coverage in a Managed Care | ||||||
19 | Organization during the base year. Member months are | ||||||
20 | determined by the Department for Medicaid Managed Care | ||||||
21 | Organizations based on enrollment data in its Medicaid | ||||||
22 | Management Information System and by the Department of | ||||||
23 | Insurance for other Managed Care Organizations based on | ||||||
24 | required filings with the Department of Insurance. Member | ||||||
25 | months do not include months individuals are enrolled in a | ||||||
26 | Limited Health Services Organization, including stand-alone |
| |||||||
| |||||||
1 | dental or vision plans, a Medicare Advantage Plan, a Medicare | ||||||
2 | Supplement Plan, a Medicaid Medicare Alignment Initiate Plan | ||||||
3 | pursuant to a Memorandum of Understanding between the | ||||||
4 | Department and the Federal Centers for Medicare and Medicaid | ||||||
5 | Services or a Federal Employee Health Benefits Plan. | ||||||
6 | (Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.) | ||||||
7 | (305 ILCS 5/5H-3) | ||||||
8 | Sec. 5H-3. Managed care assessment. | ||||||
9 | (a) There is For State Fiscal year 2020 through State | ||||||
10 | Fiscal Year 2025, there is imposed upon managed care | ||||||
11 | organization member months an assessment, calculated on base | ||||||
12 | year data, as set forth below for the appropriate tier: | ||||||
13 | (1) Tier 1: $78.90 $60.20 per member month. | ||||||
14 | (2) Tier 2: $1.40 $1.20 per member month. | ||||||
15 | (3) Tier 3: $2.40 per member month. | ||||||
16 | (b) The tiers are established as follows: | ||||||
17 | (1) Tier 1 includes the first 4,195,000 member months | ||||||
18 | in a Medicaid managed care organization for the base year; | ||||||
19 | (2) (ii) Tier 2 includes member months over 4,195,000 | ||||||
20 | in a Medicaid managed care organization during the base | ||||||
21 | year; and | ||||||
22 | (3) (iv) Tier 3 includes member months during the base | ||||||
23 | year in a managed care organization that is not a Medicaid | ||||||
24 | managed care organization. | ||||||
25 | (c) For State fiscal year 2020 , and for each State fiscal |
| |||||||
| |||||||
1 | year thereafter, through State fiscal year 2025, the | ||||||
2 | Department may by rule adjust rates or tier parameters or both | ||||||
3 | in order to maximize the revenue generated by the assessment | ||||||
4 | consistent with federal regulations and to meet federal | ||||||
5 | statistical tests necessary for federal financial | ||||||
6 | participation. Any upward adjustment to the Tier 3 rate shall | ||||||
7 | be the minimum necessary to meet federal statistical tests. | ||||||
8 | (Source: P.A. 101-9, eff. 6-5-19.) | ||||||
9 | ARTICLE 35. | ||||||
10 | Section 35-5. The Illinois Administrative Procedure Act is | ||||||
11 | amended by adding Section 5-45.55 as follows: | ||||||
12 | (5 ILCS 100/5-45.55 new) | ||||||
13 | Sec. 5-45.55. Emergency rulemaking; Medicaid hospital rate | ||||||
14 | updates. To provide for the expeditious and timely | ||||||
15 | implementation of the changes made to Section 14-12.5 of the | ||||||
16 | Illinois Public Aid Code by this amendatory Act of the 103rd | ||||||
17 | General Assembly, emergency rules implementing the changes | ||||||
18 | made by this amendatory Act of the 103rd General Assembly to | ||||||
19 | Section 14-12.5 of the Illinois Public Aid Code may be adopted | ||||||
20 | in accordance with Section 5-45 by the Department of | ||||||
21 | Healthcare and Family Services. The adoption of emergency | ||||||
22 | rules authorized by Section 5-45 and this Section is deemed to | ||||||
23 | be necessary for the public interest, safety, and welfare. |
| |||||||
| |||||||
1 | This Section is repealed one year after the effective date | ||||||
2 | of this amendatory Act of the 103rd General Assembly. | ||||||
3 | Section 35-10. The Illinois Public Aid Code is amended by | ||||||
4 | changing Section 14-12.5 as follows: | ||||||
5 | (305 ILCS 5/14-12.5) | ||||||
6 | Sec. 14-12.5. Hospital rate updates. | ||||||
7 | (a) Notwithstanding any other provision of this Code, the | ||||||
8 | hospital rates of reimbursement authorized under Sections | ||||||
9 | 5-5.05, 14-12, and 14-13 of this Code shall be adjusted in | ||||||
10 | accordance with the provisions of this Section. | ||||||
11 | (b) Notwithstanding any other provision of this Code, | ||||||
12 | effective for dates of service on and after January 1, 2024, | ||||||
13 | subject to federal approval, hospital reimbursement rates | ||||||
14 | shall be revised as follows: | ||||||
15 | (1) For inpatient general acute care services, the | ||||||
16 | statewide-standardized amount and the per diem rates for | ||||||
17 | hospitals exempt from the APR-DRG reimbursement system, in | ||||||
18 | effect January 1, 2023, shall be increased by 10%. | ||||||
19 | (2) For inpatient psychiatric services: | ||||||
20 | (A) For safety-net hospitals, the hospital | ||||||
21 | specific per diem rate in effect January 1, 2023 and | ||||||
22 | the minimum per diem rate of $630, authorized in | ||||||
23 | subsection (b-5) of Section 5-5.05 of this Code, shall | ||||||
24 | be increased by 10%. |
| |||||||
| |||||||
1 | (B) For all general acute care hospitals that are | ||||||
2 | not safety-net hospitals, the inpatient psychiatric | ||||||
3 | care per diem rates in effect January 1, 2023 shall be | ||||||
4 | increased by 10%, except that all rates shall be at | ||||||
5 | least 90% of the minimum inpatient psychiatric care | ||||||
6 | per diem rate for safety-net hospitals as authorized | ||||||
7 | in subsection (b-5) of Section 5-5.05 of this Code | ||||||
8 | including the adjustments authorized in this Section. | ||||||
9 | The statewide default per diem rate for a hospital | ||||||
10 | opening a new psychiatric distinct part unit, shall be | ||||||
11 | set at 90% of the minimum inpatient psychiatric care | ||||||
12 | per diem rate for safety-net hospitals as authorized | ||||||
13 | in subsection (b-5) of Section 5-5.05 of this Code, | ||||||
14 | including the adjustment authorized in this Section. | ||||||
15 | (C) For all psychiatric specialty hospitals, the | ||||||
16 | per diem rates in effect January 1, 2023, shall be | ||||||
17 | increased by 10%, except that all rates shall be at | ||||||
18 | least 90% of the minimum inpatient per diem rate for | ||||||
19 | safety-net hospitals as authorized in subsection (b-5) | ||||||
20 | of Section 5-5.05 of this Code, including the | ||||||
21 | adjustments authorized in this Section. The statewide | ||||||
22 | default per diem rate for a new psychiatric specialty | ||||||
23 | hospital shall be set at 90% of the minimum inpatient | ||||||
24 | psychiatric care per diem rate for safety-net | ||||||
25 | hospitals as authorized in subsection (b-5) of Section | ||||||
26 | 5-5.05 of this Code, including the adjustment |
| |||||||
| |||||||
1 | authorized in this Section. | ||||||
2 | (3) For inpatient rehabilitative services, all | ||||||
3 | hospital specific per diem rates in effect January 1, | ||||||
4 | 2023, shall be increased by 10%. The statewide default | ||||||
5 | inpatient rehabilitative services per diem rates, for | ||||||
6 | general acute care hospitals and for rehabilitation | ||||||
7 | specialty hospitals respectively, shall be increased by | ||||||
8 | 10%. | ||||||
9 | (4) The statewide-standardized amount for outpatient | ||||||
10 | general acute care services in effect January 1, 2023, | ||||||
11 | shall be increased by 10%. | ||||||
12 | (5) The statewide-standardized amount for outpatient | ||||||
13 | psychiatric care services in effect January 1, 2023, shall | ||||||
14 | be increased by 10%. | ||||||
15 | (6) The statewide-standardized amount for outpatient | ||||||
16 | rehabilitative care services in effect January 1, 2023, | ||||||
17 | shall be increased by 10%. | ||||||
18 | (7) The per diem rate in effect January 1, 2023, as | ||||||
19 | authorized in subsection (a) of Section 14-13 of this | ||||||
20 | Article shall be increased by 10%. | ||||||
21 | (8) For services provided Beginning on and after | ||||||
22 | January 1, 2024 through June 30, 2024, and on and after | ||||||
23 | January 1, 2027 , subject to federal approval, in addition | ||||||
24 | to the statewide standardized amount, an add-on payment of | ||||||
25 | at least $210 shall be paid for each inpatient General | ||||||
26 | Acute and Psychiatric day of care, excluding |
| |||||||
| |||||||
1 | Medicare-Medicaid dual eligible crossover days, for all | ||||||
2 | safety-net hospitals defined in Section 5-5e.1 of this | ||||||
3 | Code. | ||||||
4 | (A) For Psychiatric days of care, the Department | ||||||
5 | may implement payment of this add-on by increasing the | ||||||
6 | hospital specific psychiatric per diem rate, adjusted | ||||||
7 | in accordance with subparagraph (A) of paragraph (2) | ||||||
8 | of subsection (b) by $210, or by a separate add-on | ||||||
9 | payment. | ||||||
10 | (B) If the add-on adjustment is added to the | ||||||
11 | hospital specific psychiatric per diem rate to | ||||||
12 | operationalize payment, the Department shall provide a | ||||||
13 | rate sheet to each safety-net hospital, which | ||||||
14 | identifies the hospital psychiatric per diem rate | ||||||
15 | before and after the adjustment. | ||||||
16 | (C) The add-on adjustment shall not be considered | ||||||
17 | when setting the 90% minimum rate identified in | ||||||
18 | paragraph (2) of subsection (b). | ||||||
19 | (9) For services provided on and after July 1, 2024, | ||||||
20 | and on or before December 31, 2026, subject to federal | ||||||
21 | approval, in addition to the statewide standardized amount | ||||||
22 | and any other payments authorized under this Code, a | ||||||
23 | safety-net hospital health care equity add-on payment | ||||||
24 | shall be paid for each inpatient General Acute and | ||||||
25 | Psychiatric day of care, excluding Medicare-Medicaid dual | ||||||
26 | eligible crossover days, for safety-net hospitals defined |
| |||||||
| |||||||
1 | in Section 5-5e.1 of this Code, as follows: | ||||||
2 | (A) if the safety-net hospital's Medicaid | ||||||
3 | inpatient utilization rate, as calculated under | ||||||
4 | Section 5-5e.1 of this Code, is equal to or greater | ||||||
5 | than 70%, the add-on payment shall be $425; | ||||||
6 | (B) if the safety-net hospital's Medicaid | ||||||
7 | inpatient utilization rate, as calculated under | ||||||
8 | Section 5-5e.1 of this Code, is equal to or greater | ||||||
9 | than 50% and less than 70%, the add-on payment shall be | ||||||
10 | $300; | ||||||
11 | (C) if the safety-net hospital's Medicaid | ||||||
12 | inpatient utilization rate, as calculated under | ||||||
13 | Section 5-5e.1 of this Code, is equal to or greater | ||||||
14 | than 40% and less than 50%, the add-on payment shall be | ||||||
15 | $225; and | ||||||
16 | (D) if the safety-net hospital's Medicaid | ||||||
17 | inpatient utilization rate, as calculated under | ||||||
18 | Section 5-5e.1 of this Code, is less than 40%, the | ||||||
19 | add-on payment shall be $210. | ||||||
20 | Qualification for the safety-net hospital health care | ||||||
21 | equity add-on payment shall be updated January 1, 2026, | ||||||
22 | based on the MIUR determination effective 3 months prior | ||||||
23 | to the start of the January 1, 2026 calendar year. | ||||||
24 | Rates described in subparagraphs (A) through (C) shall | ||||||
25 | be adjusted annually beginning January 1, 2026 by applying | ||||||
26 | a uniform factor to each rate to spend an approximate |
| |||||||
| |||||||
1 | amount of $50,000,000 annually per year using State fiscal | ||||||
2 | year 2024 days as a basis for calendar year 2026 rates. | ||||||
3 | The add-on adjustment under this paragraph shall not | ||||||
4 | be considered when setting the 90% minimum rate identified | ||||||
5 | in subparagraph (B) of paragraph (2). | ||||||
6 | (10) For services provided on and after July 1, 2024, | ||||||
7 | and on or before December 31, 2026, subject to federal | ||||||
8 | approval, in addition to the statewide standardized amount | ||||||
9 | and any other payments authorized under this Code, a | ||||||
10 | safety-net hospital low volume add-on payment of $200 | ||||||
11 | shall be paid for each inpatient General Acute and | ||||||
12 | Psychiatric day of care, excluding Medicare-Medicaid dual | ||||||
13 | eligible crossover days, for any safety-net hospital as | ||||||
14 | defined in Section 5-5e.1 that provided less than 11,000 | ||||||
15 | Medicaid inpatient days of care, excluding | ||||||
16 | Medicare-Medicaid dual eligible crossover days, in the | ||||||
17 | base period. As used in this paragraph, "base period" | ||||||
18 | means State fiscal year 2022 admissions received by the | ||||||
19 | Department prior to October 1, 2023 for the payment period | ||||||
20 | July 1, 2024 through December 31, 2025, and beginning in | ||||||
21 | calendar year 2026, the State fiscal year that ends 30 | ||||||
22 | months before the applicable calendar year, such as State | ||||||
23 | fiscal year 2023 admissions received by the Department | ||||||
24 | prior to October 1, 2024, for calendar year 2026. | ||||||
25 | (c) The Department shall take all actions necessary to | ||||||
26 | ensure the changes authorized in Public Act 103-102 and this |
| |||||||
| |||||||
1 | amendatory Act of the 103rd General Assembly are in effect for | ||||||
2 | dates of service on and after the effective date of the changes | ||||||
3 | made to this Section by this amendatory Act of the 103rd | ||||||
4 | General Assembly, January 1, 2024, including publishing all | ||||||
5 | appropriate public notices, applying for federal approval of | ||||||
6 | amendments to the Illinois Title XIX State Plan, and adopting | ||||||
7 | administrative rules if necessary. | ||||||
8 | (d) The Department of Healthcare and Family Services may | ||||||
9 | adopt rules necessary to implement the changes made by Public | ||||||
10 | Act 103-102 and this amendatory Act of the 103rd General | ||||||
11 | Assembly through the use of emergency rulemaking in accordance | ||||||
12 | with Section 5-45 of the Illinois Administrative Procedure | ||||||
13 | Act. The 24-month limitation on the adoption of emergency | ||||||
14 | rules does not apply to rules adopted under this Section. The | ||||||
15 | General Assembly finds that the adoption of rules to implement | ||||||
16 | the changes made by Public Act 103-102 and this amendatory Act | ||||||
17 | of the 103rd General Assembly is deemed an emergency and | ||||||
18 | necessary for the public interest, safety, and welfare. | ||||||
19 | (e) The Department shall ensure that all necessary | ||||||
20 | adjustments to the managed care organization capitation base | ||||||
21 | rates necessitated by the adjustments in this Section are | ||||||
22 | completed, published, and applied in accordance with Section | ||||||
23 | 5-30.8 of this Code 90 days prior to the implementation date of | ||||||
24 | the changes required under Public Act 103-102 and this | ||||||
25 | amendatory Act of the 103rd General Assembly. | ||||||
26 | (f) The Department shall publish updated rate sheets or |
| |||||||
| |||||||
1 | add-on payment amounts, as applicable, for all hospitals 30 | ||||||
2 | days prior to the effective date of the rate increase, or | ||||||
3 | within 30 days after federal approval by the Centers for | ||||||
4 | Medicare and Medicaid Services, whichever is later. | ||||||
5 | (Source: P.A. 103-102, eff. 6-16-23.) | ||||||
6 | ARTICLE 40. | ||||||
7 | Section 40-5. The Illinois Public Aid Code is amended by | ||||||
8 | changing Section 5A-12.7 as follows: | ||||||
9 | (305 ILCS 5/5A-12.7) | ||||||
10 | (Section scheduled to be repealed on December 31, 2026) | ||||||
11 | Sec. 5A-12.7. Continuation of hospital access payments on | ||||||
12 | and after July 1, 2020. | ||||||
13 | (a) To preserve and improve access to hospital services, | ||||||
14 | for hospital services rendered on and after July 1, 2020, the | ||||||
15 | Department shall, except for hospitals described in subsection | ||||||
16 | (b) of Section 5A-3, make payments to hospitals or require | ||||||
17 | capitated managed care organizations to make payments as set | ||||||
18 | forth in this Section. Payments under this Section are not due | ||||||
19 | and payable, however, until: (i) the methodologies described | ||||||
20 | in this Section are approved by the federal government in an | ||||||
21 | appropriate State Plan amendment or directed payment preprint; | ||||||
22 | and (ii) the assessment imposed under this Article is | ||||||
23 | determined to be a permissible tax under Title XIX of the |
| |||||||
| |||||||
1 | Social Security Act. In determining the hospital access | ||||||
2 | payments authorized under subsection (g) of this Section, if a | ||||||
3 | hospital ceases to qualify for payments from the pool, the | ||||||
4 | payments for all hospitals continuing to qualify for payments | ||||||
5 | from such pool shall be uniformly adjusted to fully expend the | ||||||
6 | aggregate net amount of the pool, with such adjustment being | ||||||
7 | effective on the first day of the second month following the | ||||||
8 | date the hospital ceases to receive payments from such pool. | ||||||
9 | (b) Amounts moved into claims-based rates and distributed | ||||||
10 | in accordance with Section 14-12 shall remain in those | ||||||
11 | claims-based rates. | ||||||
12 | (c) Graduate medical education. | ||||||
13 | (1) The calculation of graduate medical education | ||||||
14 | payments shall be based on the hospital's Medicare cost | ||||||
15 | report ending in Calendar Year 2018, as reported in the | ||||||
16 | Healthcare Cost Report Information System file, release | ||||||
17 | date September 30, 2019. An Illinois hospital reporting | ||||||
18 | intern and resident cost on its Medicare cost report shall | ||||||
19 | be eligible for graduate medical education payments. | ||||||
20 | (2) Each hospital's annualized Medicaid Intern | ||||||
21 | Resident Cost is calculated using annualized intern and | ||||||
22 | resident total costs obtained from Worksheet B Part I, | ||||||
23 | Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93, | ||||||
24 | 96-98, and 105-112 multiplied by the percentage that the | ||||||
25 | hospital's Medicaid days (Worksheet S3 Part I, Column 7, | ||||||
26 | Lines 2, 3, 4, 14, 16-18, and 32) comprise of the |
| |||||||
| |||||||
1 | hospital's total days (Worksheet S3 Part I, Column 8, | ||||||
2 | Lines 14, 16-18, and 32). | ||||||
3 | (3) An annualized Medicaid indirect medical education | ||||||
4 | (IME) payment is calculated for each hospital using its | ||||||
5 | IME payments (Worksheet E Part A, Line 29, Column 1) | ||||||
6 | multiplied by the percentage that its Medicaid days | ||||||
7 | (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18, | ||||||
8 | and 32) comprise of its Medicare days (Worksheet S3 Part | ||||||
9 | I, Column 6, Lines 2, 3, 4, 14, and 16-18). | ||||||
10 | (4) For each hospital, its annualized Medicaid Intern | ||||||
11 | Resident Cost and its annualized Medicaid IME payment are | ||||||
12 | summed, and, except as capped at 120% of the average cost | ||||||
13 | per intern and resident for all qualifying hospitals as | ||||||
14 | calculated under this paragraph, is multiplied by the | ||||||
15 | applicable reimbursement factor as described in this | ||||||
16 | paragraph, to determine the hospital's final graduate | ||||||
17 | medical education payment. Each hospital's average cost | ||||||
18 | per intern and resident shall be calculated by summing its | ||||||
19 | total annualized Medicaid Intern Resident Cost plus its | ||||||
20 | annualized Medicaid IME payment and dividing that amount | ||||||
21 | by the hospital's total Full Time Equivalent Residents and | ||||||
22 | Interns. If the hospital's average per intern and resident | ||||||
23 | cost is greater than 120% of the same calculation for all | ||||||
24 | qualifying hospitals, the hospital's per intern and | ||||||
25 | resident cost shall be capped at 120% of the average cost | ||||||
26 | for all qualifying hospitals. |
| |||||||
| |||||||
1 | (A) For the period of July 1, 2020 through | ||||||
2 | December 31, 2022, the applicable reimbursement factor | ||||||
3 | shall be 22.6%. | ||||||
4 | (B) For the period of January 1, 2023 through | ||||||
5 | December 31, 2026, the applicable reimbursement factor | ||||||
6 | shall be 35% for all qualified safety-net hospitals, | ||||||
7 | as defined in Section 5-5e.1 of this Code, and all | ||||||
8 | hospitals with 100 or more Full Time Equivalent | ||||||
9 | Residents and Interns, as reported on the hospital's | ||||||
10 | Medicare cost report ending in Calendar Year 2018, and | ||||||
11 | for all other qualified hospitals the applicable | ||||||
12 | reimbursement factor shall be 30%. | ||||||
13 | (d) Fee-for-service supplemental payments. For the period | ||||||
14 | of July 1, 2020 through December 31, 2022, each Illinois | ||||||
15 | hospital shall receive an annual payment equal to the amounts | ||||||
16 | below, to be paid in 12 equal installments on or before the | ||||||
17 | seventh State business day of each month, except that no | ||||||
18 | payment shall be due within 30 days after the later of the date | ||||||
19 | of notification of federal approval of the payment | ||||||
20 | methodologies required under this Section or any waiver | ||||||
21 | required under 42 CFR 433.68, at which time the sum of amounts | ||||||
22 | required under this Section prior to the date of notification | ||||||
23 | is due and payable. | ||||||
24 | (1) For critical access hospitals, $385 per covered | ||||||
25 | inpatient day contained in paid fee-for-service claims and | ||||||
26 | $530 per paid fee-for-service outpatient claim for dates |
| |||||||
| |||||||
1 | of service in Calendar Year 2019 in the Department's | ||||||
2 | Enterprise Data Warehouse as of May 11, 2020. | ||||||
3 | (2) For safety-net hospitals, $960 per covered | ||||||
4 | inpatient day contained in paid fee-for-service claims and | ||||||
5 | $625 per paid fee-for-service outpatient claim for dates | ||||||
6 | of service in Calendar Year 2019 in the Department's | ||||||
7 | Enterprise Data Warehouse as of May 11, 2020. | ||||||
8 | (3) For long term acute care hospitals, $295 per | ||||||
9 | covered inpatient day contained in paid fee-for-service | ||||||
10 | claims for dates of service in Calendar Year 2019 in the | ||||||
11 | Department's Enterprise Data Warehouse as of May 11, 2020. | ||||||
12 | (4) For freestanding psychiatric hospitals, $125 per | ||||||
13 | covered inpatient day contained in paid fee-for-service | ||||||
14 | claims and $130 per paid fee-for-service outpatient claim | ||||||
15 | for dates of service in Calendar Year 2019 in the | ||||||
16 | Department's Enterprise Data Warehouse as of May 11, 2020. | ||||||
17 | (5) For freestanding rehabilitation hospitals, $355 | ||||||
18 | per covered inpatient day contained in paid | ||||||
19 | fee-for-service claims for dates of service in Calendar | ||||||
20 | Year 2019 in the Department's Enterprise Data Warehouse as | ||||||
21 | of May 11, 2020. | ||||||
22 | (6) For all general acute care hospitals and high | ||||||
23 | Medicaid hospitals as defined in subsection (f), $350 per | ||||||
24 | covered inpatient day for dates of service in Calendar | ||||||
25 | Year 2019 contained in paid fee-for-service claims and | ||||||
26 | $620 per paid fee-for-service outpatient claim in the |
| |||||||
| |||||||
1 | Department's Enterprise Data Warehouse as of May 11, 2020. | ||||||
2 | (7) Alzheimer's treatment access payment. Each | ||||||
3 | Illinois academic medical center or teaching hospital, as | ||||||
4 | defined in Section 5-5e.2 of this Code, that is identified | ||||||
5 | as the primary hospital affiliate of one of the Regional | ||||||
6 | Alzheimer's Disease Assistance Centers, as designated by | ||||||
7 | the Alzheimer's Disease Assistance Act and identified in | ||||||
8 | the Department of Public Health's Alzheimer's Disease | ||||||
9 | State Plan dated December 2016, shall be paid an | ||||||
10 | Alzheimer's treatment access payment equal to the product | ||||||
11 | of the qualifying hospital's State Fiscal Year 2018 total | ||||||
12 | inpatient fee-for-service days multiplied by the | ||||||
13 | applicable Alzheimer's treatment rate of $226.30 for | ||||||
14 | hospitals located in Cook County and $116.21 for hospitals | ||||||
15 | located outside Cook County. | ||||||
16 | (d-2) Fee-for-service supplemental payments. Beginning | ||||||
17 | January 1, 2023, each Illinois hospital shall receive an | ||||||
18 | annual payment equal to the amounts listed below, to be paid in | ||||||
19 | 12 equal installments on or before the seventh State business | ||||||
20 | day of each month, except that no payment shall be due within | ||||||
21 | 30 days after the later of the date of notification of federal | ||||||
22 | approval of the payment methodologies required under this | ||||||
23 | Section or any waiver required under 42 CFR 433.68, at which | ||||||
24 | time the sum of amounts required under this Section prior to | ||||||
25 | the date of notification is due and payable. The Department | ||||||
26 | may adjust the rates in paragraphs (1) through (7) to comply |
| |||||||
| |||||||
1 | with the federal upper payment limits, with such adjustments | ||||||
2 | being determined so that the total estimated spending by | ||||||
3 | hospital class, under such adjusted rates, remains | ||||||
4 | substantially similar to the total estimated spending under | ||||||
5 | the original rates set forth in this subsection. | ||||||
6 | (1) For critical access hospitals, as defined in | ||||||
7 | subsection (f), $750 per covered inpatient day contained | ||||||
8 | in paid fee-for-service claims and $750 per paid | ||||||
9 | fee-for-service outpatient claim for dates of service in | ||||||
10 | Calendar Year 2019 in the Department's Enterprise Data | ||||||
11 | Warehouse as of August 6, 2021. | ||||||
12 | (2) For safety-net hospitals, as described in | ||||||
13 | subsection (f), $1,350 per inpatient day contained in paid | ||||||
14 | fee-for-service claims and $1,350 per paid fee-for-service | ||||||
15 | outpatient claim for dates of service in Calendar Year | ||||||
16 | 2019 in the Department's Enterprise Data Warehouse as of | ||||||
17 | August 6, 2021. | ||||||
18 | (3) For long term acute care hospitals, $550 per | ||||||
19 | covered inpatient day contained in paid fee-for-service | ||||||
20 | claims for dates of service in Calendar Year 2019 in the | ||||||
21 | Department's Enterprise Data Warehouse as of August 6, | ||||||
22 | 2021. | ||||||
23 | (4) For freestanding psychiatric hospitals, $200 per | ||||||
24 | covered inpatient day contained in paid fee-for-service | ||||||
25 | claims and $200 per paid fee-for-service outpatient claim | ||||||
26 | for dates of service in Calendar Year 2019 in the |
| |||||||
| |||||||
1 | Department's Enterprise Data Warehouse as of August 6, | ||||||
2 | 2021. | ||||||
3 | (5) For freestanding rehabilitation hospitals, $550 | ||||||
4 | per covered inpatient day contained in paid | ||||||
5 | fee-for-service claims and $125 per paid fee-for-service | ||||||
6 | outpatient claim for dates of service in Calendar Year | ||||||
7 | 2019 in the Department's Enterprise Data Warehouse as of | ||||||
8 | August 6, 2021. | ||||||
9 | (6) For all general acute care hospitals and high | ||||||
10 | Medicaid hospitals as defined in subsection (f), $500 per | ||||||
11 | covered inpatient day for dates of service in Calendar | ||||||
12 | Year 2019 contained in paid fee-for-service claims and | ||||||
13 | $500 per paid fee-for-service outpatient claim in the | ||||||
14 | Department's Enterprise Data Warehouse as of August 6, | ||||||
15 | 2021. | ||||||
16 | (7) For public hospitals, as defined in subsection | ||||||
17 | (f), $275 per covered inpatient day contained in paid | ||||||
18 | fee-for-service claims and $275 per paid fee-for-service | ||||||
19 | outpatient claim for dates of service in Calendar Year | ||||||
20 | 2019 in the Department's Enterprise Data Warehouse as of | ||||||
21 | August 6, 2021. | ||||||
22 | (8) Alzheimer's treatment access payment. Each | ||||||
23 | Illinois academic medical center or teaching hospital, as | ||||||
24 | defined in Section 5-5e.2 of this Code, that is identified | ||||||
25 | as the primary hospital affiliate of one of the Regional | ||||||
26 | Alzheimer's Disease Assistance Centers, as designated by |
| |||||||
| |||||||
1 | the Alzheimer's Disease Assistance Act and identified in | ||||||
2 | the Department of Public Health's Alzheimer's Disease | ||||||
3 | State Plan dated December 2016, shall be paid an | ||||||
4 | Alzheimer's treatment access payment equal to the product | ||||||
5 | of the qualifying hospital's Calendar Year 2019 total | ||||||
6 | inpatient fee-for-service days, in the Department's | ||||||
7 | Enterprise Data Warehouse as of August 6, 2021, multiplied | ||||||
8 | by the applicable Alzheimer's treatment rate of $244.37 | ||||||
9 | for hospitals located in Cook County and $312.03 for | ||||||
10 | hospitals located outside Cook County. | ||||||
11 | (e) The Department shall require managed care | ||||||
12 | organizations (MCOs) to make directed payments and | ||||||
13 | pass-through payments according to this Section. Each calendar | ||||||
14 | year, the Department shall require MCOs to pay the maximum | ||||||
15 | amount out of these funds as allowed as pass-through payments | ||||||
16 | under federal regulations. The Department shall require MCOs | ||||||
17 | to make such pass-through payments as specified in this | ||||||
18 | Section. The Department shall require the MCOs to pay the | ||||||
19 | remaining amounts as directed Payments as specified in this | ||||||
20 | Section. The Department shall issue payments to the | ||||||
21 | Comptroller by the seventh business day of each month for all | ||||||
22 | MCOs that are sufficient for MCOs to make the directed | ||||||
23 | payments and pass-through payments according to this Section. | ||||||
24 | The Department shall require the MCOs to make pass-through | ||||||
25 | payments and directed payments using electronic funds | ||||||
26 | transfers (EFT), if the hospital provides the information |
| |||||||
| |||||||
1 | necessary to process such EFTs, in accordance with directions | ||||||
2 | provided monthly by the Department, within 7 business days of | ||||||
3 | the date the funds are paid to the MCOs, as indicated by the | ||||||
4 | "Paid Date" on the website of the Office of the Comptroller if | ||||||
5 | the funds are paid by EFT and the MCOs have received directed | ||||||
6 | payment instructions. If funds are not paid through the | ||||||
7 | Comptroller by EFT, payment must be made within 7 business | ||||||
8 | days of the date actually received by the MCO. The MCO will be | ||||||
9 | considered to have paid the pass-through payments when the | ||||||
10 | payment remittance number is generated or the date the MCO | ||||||
11 | sends the check to the hospital, if EFT information is not | ||||||
12 | supplied. If an MCO is late in paying a pass-through payment or | ||||||
13 | directed payment as required under this Section (including any | ||||||
14 | extensions granted by the Department), it shall pay a penalty, | ||||||
15 | unless waived by the Department for reasonable cause, to the | ||||||
16 | Department equal to 5% of the amount of the pass-through | ||||||
17 | payment or directed payment not paid on or before the due date | ||||||
18 | plus 5% of the portion thereof remaining unpaid on the last day | ||||||
19 | of each 30-day period thereafter. Payments to MCOs that would | ||||||
20 | be paid consistent with actuarial certification and enrollment | ||||||
21 | in the absence of the increased capitation payments under this | ||||||
22 | Section shall not be reduced as a consequence of payments made | ||||||
23 | under this subsection. The Department shall publish and | ||||||
24 | maintain on its website for a period of no less than 8 calendar | ||||||
25 | quarters, the quarterly calculation of directed payments and | ||||||
26 | pass-through payments owed to each hospital from each MCO. All |
| |||||||
| |||||||
1 | calculations and reports shall be posted no later than the | ||||||
2 | first day of the quarter for which the payments are to be | ||||||
3 | issued. | ||||||
4 | (f)(1) For purposes of allocating the funds included in | ||||||
5 | capitation payments to MCOs, Illinois hospitals shall be | ||||||
6 | divided into the following classes as defined in | ||||||
7 | administrative rules: | ||||||
8 | (A) Beginning July 1, 2020 through December 31, 2022, | ||||||
9 | critical access hospitals. Beginning January 1, 2023, | ||||||
10 | "critical access hospital" means a hospital designated by | ||||||
11 | the Department of Public Health as a critical access | ||||||
12 | hospital, excluding any hospital meeting the definition of | ||||||
13 | a public hospital in subparagraph (F). | ||||||
14 | (B) Safety-net hospitals, except that stand-alone | ||||||
15 | children's hospitals that are not specialty children's | ||||||
16 | hospitals and, for calendar years 2025 and 2026 only, | ||||||
17 | hospitals with over 9,000 Medicaid acute care inpatient | ||||||
18 | admissions per calendar year, excluding admissions for | ||||||
19 | Medicare-Medicaid dual eligible patients, will not be | ||||||
20 | included. For the calendar year beginning January 1, 2023, | ||||||
21 | and each calendar year thereafter, assignment to the | ||||||
22 | safety-net class shall be based on the annual safety-net | ||||||
23 | rate year beginning 15 months before the beginning of the | ||||||
24 | first Payout Quarter of the calendar year. | ||||||
25 | (C) Long term acute care hospitals. | ||||||
26 | (D) Freestanding psychiatric hospitals. |
| |||||||
| |||||||
1 | (E) Freestanding rehabilitation hospitals. | ||||||
2 | (F) Beginning January 1, 2023, "public hospital" means | ||||||
3 | a hospital that is owned or operated by an Illinois | ||||||
4 | Government body or municipality, excluding a hospital | ||||||
5 | provider that is a State agency, a State university, or a | ||||||
6 | county with a population of 3,000,000 or more. | ||||||
7 | (G) High Medicaid hospitals. | ||||||
8 | (i) As used in this Section, "high Medicaid | ||||||
9 | hospital" means a general acute care hospital that: | ||||||
10 | (I) For the payout periods July 1, 2020 | ||||||
11 | through December 31, 2022, is not a safety-net | ||||||
12 | hospital or critical access hospital and that has | ||||||
13 | a Medicaid Inpatient Utilization Rate above 30% or | ||||||
14 | a hospital that had over 35,000 inpatient Medicaid | ||||||
15 | days during the applicable period. For the period | ||||||
16 | July 1, 2020 through December 31, 2020, the | ||||||
17 | applicable period for the Medicaid Inpatient | ||||||
18 | Utilization Rate (MIUR) is the rate year 2020 MIUR | ||||||
19 | and for the number of inpatient days it is State | ||||||
20 | fiscal year 2018. Beginning in calendar year 2021, | ||||||
21 | the Department shall use the most recently | ||||||
22 | determined MIUR, as defined in subsection (h) of | ||||||
23 | Section 5-5.02, and for the inpatient day | ||||||
24 | threshold, the State fiscal year ending 18 months | ||||||
25 | prior to the beginning of the calendar year. For | ||||||
26 | purposes of calculating MIUR under this Section, |
| |||||||
| |||||||
1 | children's hospitals and affiliated general acute | ||||||
2 | care hospitals shall be considered a single | ||||||
3 | hospital. | ||||||
4 | (II) For the calendar year beginning January | ||||||
5 | 1, 2023, and each calendar year thereafter, is not | ||||||
6 | a public hospital, safety-net hospital, or | ||||||
7 | critical access hospital and that qualifies as a | ||||||
8 | regional high volume hospital or is a hospital | ||||||
9 | that has a Medicaid Inpatient Utilization Rate | ||||||
10 | (MIUR) above 30%. As used in this item, "regional | ||||||
11 | high volume hospital" means a hospital which ranks | ||||||
12 | in the top 2 quartiles based on total hospital | ||||||
13 | services volume, of all eligible general acute | ||||||
14 | care hospitals, when ranked in descending order | ||||||
15 | based on total hospital services volume, within | ||||||
16 | the same Medicaid managed care region, as | ||||||
17 | designated by the Department, as of January 1, | ||||||
18 | 2022. As used in this item, "total hospital | ||||||
19 | services volume" means the total of all Medical | ||||||
20 | Assistance hospital inpatient admissions plus all | ||||||
21 | Medical Assistance hospital outpatient visits. For | ||||||
22 | purposes of determining regional high volume | ||||||
23 | hospital inpatient admissions and outpatient | ||||||
24 | visits, the Department shall use dates of service | ||||||
25 | provided during State Fiscal Year 2020 for the | ||||||
26 | Payout Quarter beginning January 1, 2023. The |
| |||||||
| |||||||
1 | Department shall use dates of service from the | ||||||
2 | State fiscal year ending 18 month before the | ||||||
3 | beginning of the first Payout Quarter of the | ||||||
4 | subsequent annual determination period. | ||||||
5 | (ii) For the calendar year beginning January 1, | ||||||
6 | 2023, the Department shall use the Rate Year 2022 | ||||||
7 | Medicaid inpatient utilization rate (MIUR), as defined | ||||||
8 | in subsection (h) of Section 5-5.02. For each | ||||||
9 | subsequent annual determination, the Department shall | ||||||
10 | use the MIUR applicable to the rate year ending | ||||||
11 | September 30 of the year preceding the beginning of | ||||||
12 | the calendar year. | ||||||
13 | (H) General acute care hospitals. As used under this | ||||||
14 | Section, "general acute care hospitals" means all other | ||||||
15 | Illinois hospitals not identified in subparagraphs (A) | ||||||
16 | through (G). | ||||||
17 | (2) Hospitals' qualification for each class shall be | ||||||
18 | assessed prior to the beginning of each calendar year and the | ||||||
19 | new class designation shall be effective January 1 of the next | ||||||
20 | year. The Department shall publish by rule the process for | ||||||
21 | establishing class determination. | ||||||
22 | (3) Beginning January 1, 2024, the Department may reassign | ||||||
23 | hospitals or entire hospital classes as defined above, if | ||||||
24 | federal limits on the payments to the class to which the | ||||||
25 | hospitals are assigned based on the criteria in this | ||||||
26 | subsection prevent the Department from making payments to the |
| |||||||
| |||||||
1 | class that would otherwise be due under this Section. The | ||||||
2 | Department shall publish the criteria and composition of each | ||||||
3 | new class based on the reassignments, and the projected impact | ||||||
4 | on payments to each hospital under the new classes on its | ||||||
5 | website by November 15 of the year before the year in which the | ||||||
6 | class changes become effective. | ||||||
7 | (g) Fixed pool directed payments. Beginning July 1, 2020, | ||||||
8 | the Department shall issue payments to MCOs which shall be | ||||||
9 | used to issue directed payments to qualified Illinois | ||||||
10 | safety-net hospitals and critical access hospitals on a | ||||||
11 | monthly basis in accordance with this subsection. Prior to the | ||||||
12 | beginning of each Payout Quarter beginning July 1, 2020, the | ||||||
13 | Department shall use encounter claims data from the | ||||||
14 | Determination Quarter, accepted by the Department's Medicaid | ||||||
15 | Management Information System for inpatient and outpatient | ||||||
16 | services rendered by safety-net hospitals and critical access | ||||||
17 | hospitals to determine a quarterly uniform per unit add-on for | ||||||
18 | each hospital class. | ||||||
19 | (1) Inpatient per unit add-on. A quarterly uniform per | ||||||
20 | diem add-on shall be derived by dividing the quarterly | ||||||
21 | Inpatient Directed Payments Pool amount allocated to the | ||||||
22 | applicable hospital class by the total inpatient days | ||||||
23 | contained on all encounter claims received during the | ||||||
24 | Determination Quarter, for all hospitals in the class. | ||||||
25 | (A) Each hospital in the class shall have a | ||||||
26 | quarterly inpatient directed payment calculated that |
| |||||||
| |||||||
1 | is equal to the product of the number of inpatient days | ||||||
2 | attributable to the hospital used in the calculation | ||||||
3 | of the quarterly uniform class per diem add-on, | ||||||
4 | multiplied by the calculated applicable quarterly | ||||||
5 | uniform class per diem add-on of the hospital class. | ||||||
6 | (B) Each hospital shall be paid 1/3 of its | ||||||
7 | quarterly inpatient directed payment in each of the 3 | ||||||
8 | months of the Payout Quarter, in accordance with | ||||||
9 | directions provided to each MCO by the Department. | ||||||
10 | (2) Outpatient per unit add-on. A quarterly uniform | ||||||
11 | per claim add-on shall be derived by dividing the | ||||||
12 | quarterly Outpatient Directed Payments Pool amount | ||||||
13 | allocated to the applicable hospital class by the total | ||||||
14 | outpatient encounter claims received during the | ||||||
15 | Determination Quarter, for all hospitals in the class. | ||||||
16 | (A) Each hospital in the class shall have a | ||||||
17 | quarterly outpatient directed payment calculated that | ||||||
18 | is equal to the product of the number of outpatient | ||||||
19 | encounter claims attributable to the hospital used in | ||||||
20 | the calculation of the quarterly uniform class per | ||||||
21 | claim add-on, multiplied by the calculated applicable | ||||||
22 | quarterly uniform class per claim add-on of the | ||||||
23 | hospital class. | ||||||
24 | (B) Each hospital shall be paid 1/3 of its | ||||||
25 | quarterly outpatient directed payment in each of the 3 | ||||||
26 | months of the Payout Quarter, in accordance with |
| |||||||
| |||||||
1 | directions provided to each MCO by the Department. | ||||||
2 | (3) Each MCO shall pay each hospital the Monthly | ||||||
3 | Directed Payment as identified by the Department on its | ||||||
4 | quarterly determination report. | ||||||
5 | (4) Definitions. As used in this subsection: | ||||||
6 | (A) "Payout Quarter" means each 3 month calendar | ||||||
7 | quarter, beginning July 1, 2020. | ||||||
8 | (B) "Determination Quarter" means each 3 month | ||||||
9 | calendar quarter, which ends 3 months prior to the | ||||||
10 | first day of each Payout Quarter. | ||||||
11 | (5) For the period July 1, 2020 through December 2020, | ||||||
12 | the following amounts shall be allocated to the following | ||||||
13 | hospital class directed payment pools for the quarterly | ||||||
14 | development of a uniform per unit add-on: | ||||||
15 | (A) $2,894,500 for hospital inpatient services for | ||||||
16 | critical access hospitals. | ||||||
17 | (B) $4,294,374 for hospital outpatient services | ||||||
18 | for critical access hospitals. | ||||||
19 | (C) $29,109,330 for hospital inpatient services | ||||||
20 | for safety-net hospitals. | ||||||
21 | (D) $35,041,218 for hospital outpatient services | ||||||
22 | for safety-net hospitals. | ||||||
23 | (6) For the period January 1, 2023 through December | ||||||
24 | 31, 2023, the Department shall establish the amounts that | ||||||
25 | shall be allocated to the hospital class directed payment | ||||||
26 | fixed pools identified in this paragraph for the quarterly |
| |||||||
| |||||||
1 | development of a uniform per unit add-on. The Department | ||||||
2 | shall establish such amounts so that the total amount of | ||||||
3 | payments to each hospital under this Section in calendar | ||||||
4 | year 2023 is projected to be substantially similar to the | ||||||
5 | total amount of such payments received by the hospital | ||||||
6 | under this Section in calendar year 2021, adjusted for | ||||||
7 | increased funding provided for fixed pool directed | ||||||
8 | payments under subsection (g) in calendar year 2022, | ||||||
9 | assuming that the volume and acuity of claims are held | ||||||
10 | constant. The Department shall publish the directed | ||||||
11 | payment fixed pool amounts to be established under this | ||||||
12 | paragraph on its website by November 15, 2022. | ||||||
13 | (A) Hospital inpatient services for critical | ||||||
14 | access hospitals. | ||||||
15 | (B) Hospital outpatient services for critical | ||||||
16 | access hospitals. | ||||||
17 | (C) Hospital inpatient services for public | ||||||
18 | hospitals. | ||||||
19 | (D) Hospital outpatient services for public | ||||||
20 | hospitals. | ||||||
21 | (E) Hospital inpatient services for safety-net | ||||||
22 | hospitals. | ||||||
23 | (F) Hospital outpatient services for safety-net | ||||||
24 | hospitals. | ||||||
25 | (7) Semi-annual rate maintenance review. The | ||||||
26 | Department shall ensure that hospitals assigned to the |
| |||||||
| |||||||
1 | fixed pools in paragraph (6) are paid no less than 95% of | ||||||
2 | the annual initial rate for each 6-month period of each | ||||||
3 | annual payout period. For each calendar year, the | ||||||
4 | Department shall calculate the annual initial rate per day | ||||||
5 | and per visit for each fixed pool hospital class listed in | ||||||
6 | paragraph (6), by dividing the total of all applicable | ||||||
7 | inpatient or outpatient directed payments issued in the | ||||||
8 | preceding calendar year to the hospitals in each fixed | ||||||
9 | pool class for the calendar year, plus any increase | ||||||
10 | resulting from the annual adjustments described in | ||||||
11 | subsection (i), by the actual applicable total service | ||||||
12 | units for the preceding calendar year which were the basis | ||||||
13 | of the total applicable inpatient or outpatient directed | ||||||
14 | payments issued to the hospitals in each fixed pool class | ||||||
15 | in the calendar year, except that for calendar year 2023, | ||||||
16 | the service units from calendar year 2021 shall be used. | ||||||
17 | (A) The Department shall calculate the effective | ||||||
18 | rate, per day and per visit, for the payout periods of | ||||||
19 | January to June and July to December of each year, for | ||||||
20 | each fixed pool listed in paragraph (6), by dividing | ||||||
21 | 50% of the annual pool by the total applicable | ||||||
22 | reported service units for the 2 applicable | ||||||
23 | determination quarters. | ||||||
24 | (B) If the effective rate calculated in | ||||||
25 | subparagraph (A) is less than 95% of the annual | ||||||
26 | initial rate assigned to the class for each pool under |
| |||||||
| |||||||
1 | paragraph (6), the Department shall adjust the payment | ||||||
2 | for each hospital to a level equal to no less than 95% | ||||||
3 | of the annual initial rate, by issuing a retroactive | ||||||
4 | adjustment payment for the 6-month period under review | ||||||
5 | as identified in subparagraph (A). | ||||||
6 | (h) Fixed rate directed payments. Effective July 1, 2020, | ||||||
7 | the Department shall issue payments to MCOs which shall be | ||||||
8 | used to issue directed payments to Illinois hospitals not | ||||||
9 | identified in paragraph (g) on a monthly basis. Prior to the | ||||||
10 | beginning of each Payout Quarter beginning July 1, 2020, the | ||||||
11 | Department shall use encounter claims data from the | ||||||
12 | Determination Quarter, accepted by the Department's Medicaid | ||||||
13 | Management Information System for inpatient and outpatient | ||||||
14 | services rendered by hospitals in each hospital class | ||||||
15 | identified in paragraph (f) and not identified in paragraph | ||||||
16 | (g). For the period July 1, 2020 through December 2020, the | ||||||
17 | Department shall direct MCOs to make payments as follows: | ||||||
18 | (1) For general acute care hospitals an amount equal | ||||||
19 | to $1,750 multiplied by the hospital's category of service | ||||||
20 | 20 case mix index for the determination quarter multiplied | ||||||
21 | by the hospital's total number of inpatient admissions for | ||||||
22 | category of service 20 for the determination quarter. | ||||||
23 | (2) For general acute care hospitals an amount equal | ||||||
24 | to $160 multiplied by the hospital's category of service | ||||||
25 | 21 case mix index for the determination quarter multiplied | ||||||
26 | by the hospital's total number of inpatient admissions for |
| |||||||
| |||||||
1 | category of service 21 for the determination quarter. | ||||||
2 | (3) For general acute care hospitals an amount equal | ||||||
3 | to $80 multiplied by the hospital's category of service 22 | ||||||
4 | case mix index for the determination quarter multiplied by | ||||||
5 | the hospital's total number of inpatient admissions for | ||||||
6 | category of service 22 for the determination quarter. | ||||||
7 | (4) For general acute care hospitals an amount equal | ||||||
8 | to $375 multiplied by the hospital's category of service | ||||||
9 | 24 case mix index for the determination quarter multiplied | ||||||
10 | by the hospital's total number of category of service 24 | ||||||
11 | paid EAPG (EAPGs) for the determination quarter. | ||||||
12 | (5) For general acute care hospitals an amount equal | ||||||
13 | to $240 multiplied by the hospital's category of service | ||||||
14 | 27 and 28 case mix index for the determination quarter | ||||||
15 | multiplied by the hospital's total number of category of | ||||||
16 | service 27 and 28 paid EAPGs for the determination | ||||||
17 | quarter. | ||||||
18 | (6) For general acute care hospitals an amount equal | ||||||
19 | to $290 multiplied by the hospital's category of service | ||||||
20 | 29 case mix index for the determination quarter multiplied | ||||||
21 | by the hospital's total number of category of service 29 | ||||||
22 | paid EAPGs for the determination quarter. | ||||||
23 | (7) For high Medicaid hospitals an amount equal to | ||||||
24 | $1,800 multiplied by the hospital's category of service 20 | ||||||
25 | case mix index for the determination quarter multiplied by | ||||||
26 | the hospital's total number of inpatient admissions for |
| |||||||
| |||||||
1 | category of service 20 for the determination quarter. | ||||||
2 | (8) For high Medicaid hospitals an amount equal to | ||||||
3 | $160 multiplied by the hospital's category of service 21 | ||||||
4 | case mix index for the determination quarter multiplied by | ||||||
5 | the hospital's total number of inpatient admissions for | ||||||
6 | category of service 21 for the determination quarter. | ||||||
7 | (9) For high Medicaid hospitals an amount equal to $80 | ||||||
8 | multiplied by the hospital's category of service 22 case | ||||||
9 | mix index for the determination quarter multiplied by the | ||||||
10 | hospital's total number of inpatient admissions for | ||||||
11 | category of service 22 for the determination quarter. | ||||||
12 | (10) For high Medicaid hospitals an amount equal to | ||||||
13 | $400 multiplied by the hospital's category of service 24 | ||||||
14 | case mix index for the determination quarter multiplied by | ||||||
15 | the hospital's total number of category of service 24 paid | ||||||
16 | EAPG outpatient claims for the determination quarter. | ||||||
17 | (11) For high Medicaid hospitals an amount equal to | ||||||
18 | $240 multiplied by the hospital's category of service 27 | ||||||
19 | and 28 case mix index for the determination quarter | ||||||
20 | multiplied by the hospital's total number of category of | ||||||
21 | service 27 and 28 paid EAPGs for the determination | ||||||
22 | quarter. | ||||||
23 | (12) For high Medicaid hospitals an amount equal to | ||||||
24 | $290 multiplied by the hospital's category of service 29 | ||||||
25 | case mix index for the determination quarter multiplied by | ||||||
26 | the hospital's total number of category of service 29 paid |
| |||||||
| |||||||
1 | EAPGs for the determination quarter. | ||||||
2 | (13) For long term acute care hospitals the amount of | ||||||
3 | $495 multiplied by the hospital's total number of | ||||||
4 | inpatient days for the determination quarter. | ||||||
5 | (14) For psychiatric hospitals the amount of $210 | ||||||
6 | multiplied by the hospital's total number of inpatient | ||||||
7 | days for category of service 21 for the determination | ||||||
8 | quarter. | ||||||
9 | (15) For psychiatric hospitals the amount of $250 | ||||||
10 | multiplied by the hospital's total number of outpatient | ||||||
11 | claims for category of service 27 and 28 for the | ||||||
12 | determination quarter. | ||||||
13 | (16) For rehabilitation hospitals the amount of $410 | ||||||
14 | multiplied by the hospital's total number of inpatient | ||||||
15 | days for category of service 22 for the determination | ||||||
16 | quarter. | ||||||
17 | (17) For rehabilitation hospitals the amount of $100 | ||||||
18 | multiplied by the hospital's total number of outpatient | ||||||
19 | claims for category of service 29 for the determination | ||||||
20 | quarter. | ||||||
21 | (18) Effective for the Payout Quarter beginning | ||||||
22 | January 1, 2023, for the directed payments to hospitals | ||||||
23 | required under this subsection, the Department shall | ||||||
24 | establish the amounts that shall be used to calculate such | ||||||
25 | directed payments using the methodologies specified in | ||||||
26 | this paragraph. The Department shall use a single, uniform |
| |||||||
| |||||||
1 | rate, adjusted for acuity as specified in paragraphs (1) | ||||||
2 | through (12), for all categories of inpatient services | ||||||
3 | provided by each class of hospitals and a single uniform | ||||||
4 | rate, adjusted for acuity as specified in paragraphs (1) | ||||||
5 | through (12), for all categories of outpatient services | ||||||
6 | provided by each class of hospitals. The Department shall | ||||||
7 | establish such amounts so that the total amount of | ||||||
8 | payments to each hospital under this Section in calendar | ||||||
9 | year 2023 is projected to be substantially similar to the | ||||||
10 | total amount of such payments received by the hospital | ||||||
11 | under this Section in calendar year 2021, adjusted for | ||||||
12 | increased funding provided for fixed pool directed | ||||||
13 | payments under subsection (g) in calendar year 2022, | ||||||
14 | assuming that the volume and acuity of claims are held | ||||||
15 | constant. The Department shall publish the directed | ||||||
16 | payment amounts to be established under this subsection on | ||||||
17 | its website by November 15, 2022. | ||||||
18 | (19) Each hospital shall be paid 1/3 of their | ||||||
19 | quarterly inpatient and outpatient directed payment in | ||||||
20 | each of the 3 months of the Payout Quarter, in accordance | ||||||
21 | with directions provided to each MCO by the Department. | ||||||
22 | ( 20 ) Each MCO shall pay each hospital the Monthly | ||||||
23 | Directed Payment amount as identified by the Department on | ||||||
24 | its quarterly determination report. | ||||||
25 | Notwithstanding any other provision of this subsection, if | ||||||
26 | the Department determines that the actual total hospital |
| |||||||
| |||||||
1 | utilization data that is used to calculate the fixed rate | ||||||
2 | directed payments is substantially different than anticipated | ||||||
3 | when the rates in this subsection were initially determined | ||||||
4 | for unforeseeable circumstances (such as the COVID-19 pandemic | ||||||
5 | or some other public health emergency), the Department may | ||||||
6 | adjust the rates specified in this subsection so that the | ||||||
7 | total directed payments approximate the total spending amount | ||||||
8 | anticipated when the rates were initially established. | ||||||
9 | Definitions. As used in this subsection: | ||||||
10 | (A) "Payout Quarter" means each calendar quarter, | ||||||
11 | beginning July 1, 2020. | ||||||
12 | (B) "Determination Quarter" means each calendar | ||||||
13 | quarter which ends 3 months prior to the first day of | ||||||
14 | each Payout Quarter. | ||||||
15 | (C) "Case mix index" means a hospital specific | ||||||
16 | calculation. For inpatient claims the case mix index | ||||||
17 | is calculated each quarter by summing the relative | ||||||
18 | weight of all inpatient Diagnosis-Related Group (DRG) | ||||||
19 | claims for a category of service in the applicable | ||||||
20 | Determination Quarter and dividing the sum by the | ||||||
21 | number of sum total of all inpatient DRG admissions | ||||||
22 | for the category of service for the associated claims. | ||||||
23 | The case mix index for outpatient claims is calculated | ||||||
24 | each quarter by summing the relative weight of all | ||||||
25 | paid EAPGs in the applicable Determination Quarter and | ||||||
26 | dividing the sum by the sum total of paid EAPGs for the |
| |||||||
| |||||||
1 | associated claims. | ||||||
2 | (i) Beginning January 1, 2021, the rates for directed | ||||||
3 | payments shall be recalculated in order to spend the | ||||||
4 | additional funds for directed payments that result from | ||||||
5 | reduction in the amount of pass-through payments allowed under | ||||||
6 | federal regulations. The additional funds for directed | ||||||
7 | payments shall be allocated proportionally to each class of | ||||||
8 | hospitals based on that class' proportion of services. | ||||||
9 | (1) Beginning January 1, 2024, the fixed pool directed | ||||||
10 | payment amounts and the associated annual initial rates | ||||||
11 | referenced in paragraph (6) of subsection (f) for each | ||||||
12 | hospital class shall be uniformly increased by a ratio of | ||||||
13 | not less than, the ratio of the total pass-through | ||||||
14 | reduction amount pursuant to paragraph (4) of subsection | ||||||
15 | (j), for the hospitals comprising the hospital fixed pool | ||||||
16 | directed payment class for the next calendar year, to the | ||||||
17 | total inpatient and outpatient directed payments for the | ||||||
18 | hospitals comprising the hospital fixed pool directed | ||||||
19 | payment class paid during the preceding calendar year. | ||||||
20 | (2) Beginning January 1, 2024, the fixed rates for the | ||||||
21 | directed payments referenced in paragraph (18) of | ||||||
22 | subsection (h) for each hospital class shall be uniformly | ||||||
23 | increased by a ratio of not less than, the ratio of the | ||||||
24 | total pass-through reduction amount pursuant to paragraph | ||||||
25 | (4) of subsection (j), for the hospitals comprising the | ||||||
26 | hospital directed payment class for the next calendar |
| |||||||
| |||||||
1 | year, to the total inpatient and outpatient directed | ||||||
2 | payments for the hospitals comprising the hospital fixed | ||||||
3 | rate directed payment class paid during the preceding | ||||||
4 | calendar year. | ||||||
5 | (j) Pass-through payments. | ||||||
6 | (1) For the period July 1, 2020 through December 31, | ||||||
7 | 2020, the Department shall assign quarterly pass-through | ||||||
8 | payments to each class of hospitals equal to one-fourth of | ||||||
9 | the following annual allocations: | ||||||
10 | (A) $390,487,095 to safety-net hospitals. | ||||||
11 | (B) $62,553,886 to critical access hospitals. | ||||||
12 | (C) $345,021,438 to high Medicaid hospitals. | ||||||
13 | (D) $551,429,071 to general acute care hospitals. | ||||||
14 | (E) $27,283,870 to long term acute care hospitals. | ||||||
15 | (F) $40,825,444 to freestanding psychiatric | ||||||
16 | hospitals. | ||||||
17 | (G) $9,652,108 to freestanding rehabilitation | ||||||
18 | hospitals. | ||||||
19 | (2) For the period of July 1, 2020 through December | ||||||
20 | 31, 2020, the pass-through payments shall at a minimum | ||||||
21 | ensure hospitals receive a total amount of monthly | ||||||
22 | payments under this Section as received in calendar year | ||||||
23 | 2019 in accordance with this Article and paragraph (1) of | ||||||
24 | subsection (d-5) of Section 14-12, exclusive of amounts | ||||||
25 | received through payments referenced in subsection (b). | ||||||
26 | (3) For the calendar year beginning January 1, 2023, |
| |||||||
| |||||||
1 | the Department shall establish the annual pass-through | ||||||
2 | allocation to each class of hospitals and the pass-through | ||||||
3 | payments to each hospital so that the total amount of | ||||||
4 | payments to each hospital under this Section in calendar | ||||||
5 | year 2023 is projected to be substantially similar to the | ||||||
6 | total amount of such payments received by the hospital | ||||||
7 | under this Section in calendar year 2021, adjusted for | ||||||
8 | increased funding provided for fixed pool directed | ||||||
9 | payments under subsection (g) in calendar year 2022, | ||||||
10 | assuming that the volume and acuity of claims are held | ||||||
11 | constant. The Department shall publish the pass-through | ||||||
12 | allocation to each class and the pass-through payments to | ||||||
13 | each hospital to be established under this subsection on | ||||||
14 | its website by November 15, 2022. | ||||||
15 | (4) For the calendar years beginning January 1, 2021 | ||||||
16 | and January 1, 2022, each hospital's pass-through payment | ||||||
17 | amount shall be reduced proportionally to the reduction of | ||||||
18 | all pass-through payments required by federal regulations. | ||||||
19 | Beginning January 1, 2024, the Department shall reduce | ||||||
20 | total pass-through payments by the minimum amount | ||||||
21 | necessary to comply with federal regulations. Pass-through | ||||||
22 | payments to safety-net hospitals , as defined in Section | ||||||
23 | 5-5e.1 of this Code, shall not be reduced until all | ||||||
24 | pass-through payments to other hospitals have been | ||||||
25 | eliminated. All other hospitals shall have their | ||||||
26 | pass-through payments reduced proportionally. |
| |||||||
| |||||||
1 | (k) At least 30 days prior to each calendar year, the | ||||||
2 | Department shall notify each hospital of changes to the | ||||||
3 | payment methodologies in this Section, including, but not | ||||||
4 | limited to, changes in the fixed rate directed payment rates, | ||||||
5 | the aggregate pass-through payment amount for all hospitals, | ||||||
6 | and the hospital's pass-through payment amount for the | ||||||
7 | upcoming calendar year. | ||||||
8 | (l) Notwithstanding any other provisions of this Section, | ||||||
9 | the Department may adopt rules to change the methodology for | ||||||
10 | directed and pass-through payments as set forth in this | ||||||
11 | Section, but only to the extent necessary to obtain federal | ||||||
12 | approval of a necessary State Plan amendment or Directed | ||||||
13 | Payment Preprint or to otherwise conform to federal law or | ||||||
14 | federal regulation. | ||||||
15 | (m) As used in this subsection, "managed care | ||||||
16 | organization" or "MCO" means an entity which contracts with | ||||||
17 | the Department to provide services where payment for medical | ||||||
18 | services is made on a capitated basis, excluding contracted | ||||||
19 | entities for dual eligible or Department of Children and | ||||||
20 | Family Services youth populations. | ||||||
21 | (n) In order to address the escalating infant mortality | ||||||
22 | rates among minority communities in Illinois, the State shall, | ||||||
23 | subject to appropriation, create a pool of funding of at least | ||||||
24 | $50,000,000 annually to be disbursed among safety-net | ||||||
25 | hospitals that maintain perinatal designation from the | ||||||
26 | Department of Public Health. The funding shall be used to |
| |||||||
| |||||||
1 | preserve or enhance OB/GYN services or other specialty | ||||||
2 | services at the receiving hospital, with the distribution of | ||||||
3 | funding to be established by rule and with consideration to | ||||||
4 | perinatal hospitals with safe birthing levels and quality | ||||||
5 | metrics for healthy mothers and babies. | ||||||
6 | (o) In order to address the growing challenges of | ||||||
7 | providing stable access to healthcare in rural Illinois, | ||||||
8 | including perinatal services, behavioral healthcare including | ||||||
9 | substance use disorder services (SUDs) and other specialty | ||||||
10 | services, and to expand access to telehealth services among | ||||||
11 | rural communities in Illinois, the Department of Healthcare | ||||||
12 | and Family Services shall administer a program to provide at | ||||||
13 | least $10,000,000 in financial support annually to critical | ||||||
14 | access hospitals for delivery of perinatal and OB/GYN | ||||||
15 | services, behavioral healthcare including SUDS, other | ||||||
16 | specialty services and telehealth services. The funding shall | ||||||
17 | be used to preserve or enhance perinatal and OB/GYN services, | ||||||
18 | behavioral healthcare including SUDS, other specialty | ||||||
19 | services, as well as the explanation of telehealth services by | ||||||
20 | the receiving hospital, with the distribution of funding to be | ||||||
21 | established by rule. | ||||||
22 | (p) For calendar year 2023, the final amounts, rates, and | ||||||
23 | payments under subsections (c), (d-2), (g), (h), and (j) shall | ||||||
24 | be established by the Department, so that the sum of the total | ||||||
25 | estimated annual payments under subsections (c), (d-2), (g), | ||||||
26 | (h), and (j) for each hospital class for calendar year 2023, is |
| |||||||
| |||||||
1 | no less than: | ||||||
2 | (1) $858,260,000 to safety-net hospitals. | ||||||
3 | (2) $86,200,000 to critical access hospitals. | ||||||
4 | (3) $1,765,000,000 to high Medicaid hospitals. | ||||||
5 | (4) $673,860,000 to general acute care hospitals. | ||||||
6 | (5) $48,330,000 to long term acute care hospitals. | ||||||
7 | (6) $89,110,000 to freestanding psychiatric hospitals. | ||||||
8 | (7) $24,300,000 to freestanding rehabilitation | ||||||
9 | hospitals. | ||||||
10 | (8) $32,570,000 to public hospitals. | ||||||
11 | (q) Hospital Pandemic Recovery Stabilization Payments. The | ||||||
12 | Department shall disburse a pool of $460,000,000 in stability | ||||||
13 | payments to hospitals prior to April 1, 2023. The allocation | ||||||
14 | of the pool shall be based on the hospital directed payment | ||||||
15 | classes and directed payments issued, during Calendar Year | ||||||
16 | 2022 with added consideration to safety net hospitals, as | ||||||
17 | defined in subdivision (f)(1)(B) of this Section, and critical | ||||||
18 | access hospitals. | ||||||
19 | (Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21; | ||||||
20 | 102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff. | ||||||
21 | 6-16-23; revised 9-21-23.) | ||||||
22 | ARTICLE 45. | ||||||
23 | Section 45-5. The Illinois Public Aid Code is amended by | ||||||
24 | adding Section 5-5.08a as follows: |
| |||||||
| |||||||
1 | (305 ILCS 5/5-5.08a new) | ||||||
2 | Sec. 5-5.08a. Renal dialysis; add-on payments for home | ||||||
3 | dialysis providers in skilled nursing facilities. | ||||||
4 | (a) Findings. The General Assembly finds the following: | ||||||
5 | (1) Home dialysis services provided on-site at skilled | ||||||
6 | nursing facilities are beneficial to nursing home | ||||||
7 | residents by permitting more time for other health and | ||||||
8 | wellness activities, and nullifying burdensome off-site | ||||||
9 | travel which carries various health care risks and | ||||||
10 | increased costs. | ||||||
11 | (2) Home dialysis for nursing home residents provides | ||||||
12 | an on-site venue for high-acuity residents to receive | ||||||
13 | dialysis services, effectively creating downstream care | ||||||
14 | opportunities for hospital patients in need of post-acute | ||||||
15 | care and dialysis, and reducing the total cost of dialysis | ||||||
16 | care. | ||||||
17 | (3) On-site home dialysis in nursing homes is costlier | ||||||
18 | for the provider than conventional outpatient dialysis, as | ||||||
19 | labor costs are greater per treatment and such patients | ||||||
20 | typically have higher acuities, necessitating more | ||||||
21 | medication and greater staff involvement to promote | ||||||
22 | patient compliance. | ||||||
23 | (b) Subject to federal approval, for dates of service | ||||||
24 | beginning on and after January 1, 2025, for home renal | ||||||
25 | dialysis provided to residents of skilled nursing facilities, |
| |||||||
| |||||||
1 | the Department shall reimburse a per-claim add-on payment to | ||||||
2 | certified home dialysis providers in accordance with this | ||||||
3 | Section. Certified home dialysis providers providing dialysis | ||||||
4 | services within a skilled nursing facility shall receive a | ||||||
5 | per-claim add-on payment of $95 per treatment. As used in this | ||||||
6 | Section, "certified home dialysis provider" means an end-stage | ||||||
7 | renal disease facility that (i) provides dialysis treatment or | ||||||
8 | dialysis training to caregivers or individuals with end-stage | ||||||
9 | renal disease and (ii) has been approved to provide dialysis | ||||||
10 | home training support services by the federal Centers for | ||||||
11 | Medicare and Medicaid Services. | ||||||
12 | ARTICLE 50. | ||||||
13 | Section 50-5. The Illinois Public Aid Code is amended by | ||||||
14 | changing Sections 5-5.07 and 14-13 as follows: | ||||||
15 | (305 ILCS 5/5-5.07) | ||||||
16 | Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem | ||||||
17 | rate. The Department of Children and Family Services shall pay | ||||||
18 | the DCFS per diem rate for inpatient psychiatric stay at a | ||||||
19 | free-standing psychiatric hospital or a hospital with a | ||||||
20 | pediatric or adolescent inpatient psychiatric unit effective | ||||||
21 | the 3rd day 11th day when a child is in the hospital beyond | ||||||
22 | medical necessity, and the parent or caregiver has denied the | ||||||
23 | child access to the home and has refused or failed to make |
| |||||||
| |||||||
1 | provisions for another living arrangement for the child or the | ||||||
2 | child's discharge is being delayed due to a pending inquiry or | ||||||
3 | investigation by the Department of Children and Family | ||||||
4 | Services. If any portion of a hospital stay is reimbursed | ||||||
5 | under this Section, the hospital stay shall not be eligible | ||||||
6 | for payment under the provisions of Section 14-13 of this | ||||||
7 | Code. | ||||||
8 | (Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by | ||||||
9 | P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21; | ||||||
10 | 102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff. | ||||||
11 | 6-2-22.) | ||||||
12 | (305 ILCS 5/14-13) | ||||||
13 | Sec. 14-13. Reimbursement for inpatient stays extended | ||||||
14 | beyond medical necessity. | ||||||
15 | (a) By October 1, 2019, the Department shall by rule | ||||||
16 | implement a methodology effective for dates of service July 1, | ||||||
17 | 2019 and later to reimburse hospitals for inpatient stays | ||||||
18 | extended beyond medical necessity due to the inability of the | ||||||
19 | Department or the managed care organization in which a | ||||||
20 | recipient is enrolled or the hospital discharge planner to | ||||||
21 | find an appropriate placement after discharge from the | ||||||
22 | hospital. The Department shall evaluate the effectiveness of | ||||||
23 | the current reimbursement rate for inpatient hospital stays | ||||||
24 | beyond medical necessity. | ||||||
25 | (b) The methodology shall provide reasonable compensation |
| |||||||
| |||||||
1 | for the services provided attributable to the days of the | ||||||
2 | extended stay for which the prevailing rate methodology | ||||||
3 | provides no reimbursement. The Department may use a day | ||||||
4 | outlier program to satisfy this requirement. The reimbursement | ||||||
5 | rate shall be set at a level so as not to act as an incentive | ||||||
6 | to avoid transfer to the appropriate level of care needed or | ||||||
7 | placement, after discharge. | ||||||
8 | (c) The Department shall require managed care | ||||||
9 | organizations to adopt this methodology or an alternative | ||||||
10 | methodology that pays at least as much as the Department's | ||||||
11 | adopted methodology unless otherwise mutually agreed upon | ||||||
12 | contractual language is developed by the provider and the | ||||||
13 | managed care organization for a risk-based or innovative | ||||||
14 | payment methodology. | ||||||
15 | (d) Days beyond medical necessity shall not be eligible | ||||||
16 | for per diem add-on payments under the Medicaid High Volume | ||||||
17 | Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA) | ||||||
18 | programs. | ||||||
19 | (e) For services covered by the fee-for-service program, | ||||||
20 | reimbursement under this Section shall only be made for days | ||||||
21 | beyond medical necessity that occur after the hospital has | ||||||
22 | notified the Department of the need for post-discharge | ||||||
23 | placement. For services covered by a managed care | ||||||
24 | organization, hospitals shall notify the appropriate managed | ||||||
25 | care organization of an admission within 24 hours of | ||||||
26 | admission. For every 24-hour period beyond the initial 24 |
| |||||||
| |||||||
1 | hours after admission that the hospital fails to notify the | ||||||
2 | managed care organization of the admission, reimbursement | ||||||
3 | under this subsection shall be reduced by one day. | ||||||
4 | (f) The Department of Children and Family Services shall | ||||||
5 | pay for all inpatient stays beginning on the 3rd day a child is | ||||||
6 | in the hospital beyond medical necessity, and the parent or | ||||||
7 | caregiver has denied the child access to the home and has | ||||||
8 | refused or failed to make provisions for another living | ||||||
9 | arrangement for the child or the child's discharge is being | ||||||
10 | delayed due to a pending inquiry or investigation by the | ||||||
11 | Department of Children and Family Services. | ||||||
12 | (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.) | ||||||
13 | ARTICLE 55. | ||||||
14 | Section 55-5. The Illinois Public Aid Code is amended by | ||||||
15 | adding Section 5-55 as follows: | ||||||
16 | (305 ILCS 5/5-55 new) | ||||||
17 | Sec. 5-55. Reimbursement for music therapy services. | ||||||
18 | Subject to federal approval, for dates of service beginning on | ||||||
19 | and after July 1, 2025, the Department shall reimburse music | ||||||
20 | therapy services provided by licensed professional music | ||||||
21 | therapists. To be eligible for reimbursement under this | ||||||
22 | Section, music therapy services must be provided by a licensed | ||||||
23 | professional music therapist authorized to practice under the |
| |||||||
| |||||||
1 | Music Therapy Licensing and Practice Act. | ||||||
2 | ARTICLE 60. | ||||||
3 | Section 60-5. The Illinois Public Aid Code is amended by | ||||||
4 | adding Section 5-60 as follows: | ||||||
5 | (305 ILCS 5/5-60 new) | ||||||
6 | Sec. 5-60. Optometric services; reimbursement rates. | ||||||
7 | Notwithstanding any other law or rule to the contrary and | ||||||
8 | subject to federal approval, for dates of service beginning on | ||||||
9 | and after January 1, 2025, the reimbursement rates for | ||||||
10 | optometric and optical services for determining refractive | ||||||
11 | state, fitting of spectacles, and fitting of bifocal | ||||||
12 | spectacles shall be increased by 35% above the rates in effect | ||||||
13 | on January 1, 2024. | ||||||
14 | ARTICLE 65. | ||||||
15 | Section 65-5. The Illinois Public Aid Code is amended by | ||||||
16 | changing Section 5-2.06 as follows: | ||||||
17 | (305 ILCS 5/5-2.06) | ||||||
18 | Sec. 5-2.06. Payment rates; Children's Community-Based | ||||||
19 | Health Care Centers. Beginning January 1, 2025 and subject to | ||||||
20 | federal approval 2020 , the Department shall, for eligible |
| |||||||
| |||||||
1 | individuals, reimburse Children's Community-Based Health Care | ||||||
2 | Centers established in the Alternative Health Care Delivery | ||||||
3 | Act and providing nursing care for the purpose of | ||||||
4 | transitioning children from a hospital to home placement or | ||||||
5 | other appropriate setting and reuniting families for a maximum | ||||||
6 | of up to 120 days on a per diem basis at the lower of the | ||||||
7 | Children's Community-Based Health Care Center's usual and | ||||||
8 | customary charge to the public or at the Department rate of | ||||||
9 | $1,300 $950 . Payments at the rate set forth in this Section are | ||||||
10 | exempt from the 2.7% rate reduction required under Section | ||||||
11 | 5-5e. | ||||||
12 | (Source: P.A. 101-10, eff. 6-5-19.) | ||||||
13 | ARTICLE 70. | ||||||
14 | Section 70-5. The Illinois Public Aid Code is amended by | ||||||
15 | adding Section 5-5.24a as follows: | ||||||
16 | (305 ILCS 5/5-5.24a new) | ||||||
17 | Sec. 5-5.24a. Remote ultrasounds and remote fetal | ||||||
18 | nonstress tests; reimbursement. | ||||||
19 | (a) Subject to federal approval, for dates of service | ||||||
20 | beginning on and after January 1, 2025, the Department shall | ||||||
21 | reimburse for remote ultrasound procedures and remote fetal | ||||||
22 | nonstress tests when the patient is in a residence or other | ||||||
23 | off-site location from the patient's provider and the same |
| |||||||
| |||||||
1 | standard of care is met as would be present during an in-person | ||||||
2 | visit. | ||||||
3 | (b) Remote ultrasounds and remote fetal nonstress tests | ||||||
4 | are only eligible for reimbursement when the provider uses | ||||||
5 | digital technology: | ||||||
6 | (1) to collect medical and other forms of health data | ||||||
7 | from a patient and to electronically transmit that | ||||||
8 | information securely to a health care provider in a | ||||||
9 | different location for interpretation and recommendation; | ||||||
10 | (2) that is compliant with the federal Health | ||||||
11 | Insurance Portability and Accountability Act of 1996; and | ||||||
12 | (3) that is approved by the U.S. Food and Drug | ||||||
13 | Administration. | ||||||
14 | (c) A fetal nonstress test is only eligible for | ||||||
15 | reimbursement with a place of service modifier for at-home | ||||||
16 | monitoring with remote monitoring solutions that are cleared | ||||||
17 | by the U.S. Food and Drug Administration for on-label use for | ||||||
18 | monitoring fetal heart rate, maternal heart rate, and uterine | ||||||
19 | activity. | ||||||
20 | (d) The Department shall issue guidance to implement the | ||||||
21 | provisions of this Section. | ||||||
22 | ARTICLE 75. | ||||||
23 | Section 75-5. The Illinois Public Aid Code is amended by | ||||||
24 | changing Section 5-2b as follows: |
| |||||||
| |||||||
1 | (305 ILCS 5/5-2b) | ||||||
2 | Sec. 5-2b. Medically fragile and technology dependent | ||||||
3 | children eligibility and program; provider reimbursement | ||||||
4 | rates. | ||||||
5 | (a) Notwithstanding any other provision of law except as | ||||||
6 | provided in Section 5-30a, on and after September 1, 2012, | ||||||
7 | subject to federal approval, medical assistance under this | ||||||
8 | Article shall be available to children who qualify as persons | ||||||
9 | with a disability, as defined under the federal Supplemental | ||||||
10 | Security Income program and who are medically fragile and | ||||||
11 | technology dependent. The program shall allow eligible | ||||||
12 | children to receive the medical assistance provided under this | ||||||
13 | Article in the community and must maximize, to the fullest | ||||||
14 | extent permissible under federal law, federal reimbursement | ||||||
15 | and family cost-sharing, including co-pays, premiums, or any | ||||||
16 | other family contributions, except that the Department shall | ||||||
17 | be permitted to incentivize the utilization of selected | ||||||
18 | services through the use of cost-sharing adjustments. The | ||||||
19 | Department shall establish the policies, procedures, | ||||||
20 | standards, services, and criteria for this program by rule. | ||||||
21 | (b) Notwithstanding any other provision of this Code, | ||||||
22 | subject to federal approval, on and after January 1, 2024, the | ||||||
23 | reimbursement rates for nursing paid through Nursing and | ||||||
24 | Personal Care Services for non-waiver customers and to | ||||||
25 | providers of private duty nursing services for children |
| |||||||
| |||||||
1 | eligible for medical assistance under this Section shall be | ||||||
2 | 20% higher than the reimbursement rates in effect for nursing | ||||||
3 | services on December 31, 2023. | ||||||
4 | (c) Notwithstanding any other provision of this Code, | ||||||
5 | subject to federal approval, on and after January 1, 2025, the | ||||||
6 | reimbursement rates for nursing paid through Nursing and | ||||||
7 | Personal Care Services for non-waiver customers and to | ||||||
8 | providers of private duty nursing services for children | ||||||
9 | eligible for medical assistance under this Section shall be 7% | ||||||
10 | higher than the reimbursement rates in effect for nursing | ||||||
11 | services on December 31, 2024. | ||||||
12 | (Source: P.A. 103-102, eff. 1-1-24 .) | ||||||
13 | ARTICLE 80. | ||||||
14 | Section 80-5. The Illinois Public Aid Code is amended by | ||||||
15 | adding Section 5-52 as follows: | ||||||
16 | (305 ILCS 5/5-52 new) | ||||||
17 | Sec. 5-52. Custom prosthetic and orthotic devices; | ||||||
18 | reimbursement rates. Subject to federal approval, for dates of | ||||||
19 | service beginning on and after January 1, 2025, the Department | ||||||
20 | shall increase the current 2024 Medicaid rate by 7% under the | ||||||
21 | medical assistance program for custom prosthetic and orthotic | ||||||
22 | devices. |
| |||||||
| |||||||
1 | ARTICLE 85. | ||||||
2 | Section 85-5. The Illinois Public Aid Code is amended by | ||||||
3 | changing Section 5-4.2 as follows: | ||||||
4 | (305 ILCS 5/5-4.2) | ||||||
5 | Sec. 5-4.2. Ambulance services payments. | ||||||
6 | (a) For ambulance services provided to a recipient of aid | ||||||
7 | under this Article on or after January 1, 1993, the Illinois | ||||||
8 | Department shall reimburse ambulance service providers at | ||||||
9 | rates calculated in accordance with this Section. It is the | ||||||
10 | intent of the General Assembly to provide adequate | ||||||
11 | reimbursement for ambulance services so as to ensure adequate | ||||||
12 | access to services for recipients of aid under this Article | ||||||
13 | and to provide appropriate incentives to ambulance service | ||||||
14 | providers to provide services in an efficient and | ||||||
15 | cost-effective manner. Thus, it is the intent of the General | ||||||
16 | Assembly that the Illinois Department implement a | ||||||
17 | reimbursement system for ambulance services that, to the | ||||||
18 | extent practicable and subject to the availability of funds | ||||||
19 | appropriated by the General Assembly for this purpose, is | ||||||
20 | consistent with the payment principles of Medicare. To ensure | ||||||
21 | uniformity between the payment principles of Medicare and | ||||||
22 | Medicaid, the Illinois Department shall follow, to the extent | ||||||
23 | necessary and practicable and subject to the availability of | ||||||
24 | funds appropriated by the General Assembly for this purpose, |
| |||||||
| |||||||
1 | the statutes, laws, regulations, policies, procedures, | ||||||
2 | principles, definitions, guidelines, and manuals used to | ||||||
3 | determine the amounts paid to ambulance service providers | ||||||
4 | under Title XVIII of the Social Security Act (Medicare). | ||||||
5 | (b) For ambulance services provided to a recipient of aid | ||||||
6 | under this Article on or after January 1, 1996, the Illinois | ||||||
7 | Department shall reimburse ambulance service providers based | ||||||
8 | upon the actual distance traveled if a natural disaster, | ||||||
9 | weather conditions, road repairs, or traffic congestion | ||||||
10 | necessitates the use of a route other than the most direct | ||||||
11 | route. | ||||||
12 | (c) For purposes of this Section, "ambulance services" | ||||||
13 | includes medical transportation services provided by means of | ||||||
14 | an ambulance, air ambulance, medi-car, service car, or taxi. | ||||||
15 | (c-1) For purposes of this Section, "ground ambulance | ||||||
16 | service" means medical transportation services that are | ||||||
17 | described as ground ambulance services by the Centers for | ||||||
18 | Medicare and Medicaid Services and provided in a vehicle that | ||||||
19 | is licensed as an ambulance by the Illinois Department of | ||||||
20 | Public Health pursuant to the Emergency Medical Services (EMS) | ||||||
21 | Systems Act. | ||||||
22 | (c-2) For purposes of this Section, "ground ambulance | ||||||
23 | service provider" means a vehicle service provider as | ||||||
24 | described in the Emergency Medical Services (EMS) Systems Act | ||||||
25 | that operates licensed ambulances for the purpose of providing | ||||||
26 | emergency ambulance services, or non-emergency ambulance |
| |||||||
| |||||||
1 | services, or both. For purposes of this Section, this includes | ||||||
2 | both ambulance providers and ambulance suppliers as described | ||||||
3 | by the Centers for Medicare and Medicaid Services. | ||||||
4 | (c-3) For purposes of this Section, "medi-car" means | ||||||
5 | transportation services provided to a patient who is confined | ||||||
6 | to a wheelchair and requires the use of a hydraulic or electric | ||||||
7 | lift or ramp and wheelchair lockdown when the patient's | ||||||
8 | condition does not require medical observation, medical | ||||||
9 | supervision, medical equipment, the administration of | ||||||
10 | medications, or the administration of oxygen. | ||||||
11 | (c-4) For purposes of this Section, "service car" means | ||||||
12 | transportation services provided to a patient by a passenger | ||||||
13 | vehicle where that patient does not require the specialized | ||||||
14 | modes described in subsection (c-1) or (c-3). | ||||||
15 | (c-5) For purposes of this Section, "air ambulance | ||||||
16 | service" means medical transport by helicopter or airplane for | ||||||
17 | patients, as defined in 29 U.S.C. 1185f(c)(1), and any service | ||||||
18 | that is described as an air ambulance service by the federal | ||||||
19 | Centers for Medicare and Medicaid Services. | ||||||
20 | (d) This Section does not prohibit separate billing by | ||||||
21 | ambulance service providers for oxygen furnished while | ||||||
22 | providing advanced life support services. | ||||||
23 | (e) Beginning with services rendered on or after July 1, | ||||||
24 | 2008, all providers of non-emergency medi-car and service car | ||||||
25 | transportation must certify that the driver and employee | ||||||
26 | attendant, as applicable, have completed a safety program |
| |||||||
| |||||||
1 | approved by the Department to protect both the patient and the | ||||||
2 | driver, prior to transporting a patient. The provider must | ||||||
3 | maintain this certification in its records. The provider shall | ||||||
4 | produce such documentation upon demand by the Department or | ||||||
5 | its representative. Failure to produce documentation of such | ||||||
6 | training shall result in recovery of any payments made by the | ||||||
7 | Department for services rendered by a non-certified driver or | ||||||
8 | employee attendant. Medi-car and service car providers must | ||||||
9 | maintain legible documentation in their records of the driver | ||||||
10 | and, as applicable, employee attendant that actually | ||||||
11 | transported the patient. Providers must recertify all drivers | ||||||
12 | and employee attendants every 3 years. If they meet the | ||||||
13 | established training components set forth by the Department, | ||||||
14 | providers of non-emergency medi-car and service car | ||||||
15 | transportation that are either directly or through an | ||||||
16 | affiliated company licensed by the Department of Public Health | ||||||
17 | shall be approved by the Department to have in-house safety | ||||||
18 | programs for training their own staff. | ||||||
19 | Notwithstanding the requirements above, any public | ||||||
20 | transportation provider of medi-car and service car | ||||||
21 | transportation that receives federal funding under 49 U.S.C. | ||||||
22 | 5307 and 5311 need not certify its drivers and employee | ||||||
23 | attendants under this Section, since safety training is | ||||||
24 | already federally mandated. | ||||||
25 | (f) With respect to any policy or program administered by | ||||||
26 | the Department or its agent regarding approval of |
| |||||||
| |||||||
1 | non-emergency medical transportation by ground ambulance | ||||||
2 | service providers, including, but not limited to, the | ||||||
3 | Non-Emergency Transportation Services Prior Approval Program | ||||||
4 | (NETSPAP), the Department shall establish by rule a process by | ||||||
5 | which ground ambulance service providers of non-emergency | ||||||
6 | medical transportation may appeal any decision by the | ||||||
7 | Department or its agent for which no denial was received prior | ||||||
8 | to the time of transport that either (i) denies a request for | ||||||
9 | approval for payment of non-emergency transportation by means | ||||||
10 | of ground ambulance service or (ii) grants a request for | ||||||
11 | approval of non-emergency transportation by means of ground | ||||||
12 | ambulance service at a level of service that entitles the | ||||||
13 | ground ambulance service provider to a lower level of | ||||||
14 | compensation from the Department than the ground ambulance | ||||||
15 | service provider would have received as compensation for the | ||||||
16 | level of service requested. The rule shall be filed by | ||||||
17 | December 15, 2012 and shall provide that, for any decision | ||||||
18 | rendered by the Department or its agent on or after the date | ||||||
19 | the rule takes effect, the ground ambulance service provider | ||||||
20 | shall have 60 days from the date the decision is received to | ||||||
21 | file an appeal. The rule established by the Department shall | ||||||
22 | be, insofar as is practical, consistent with the Illinois | ||||||
23 | Administrative Procedure Act. The Director's decision on an | ||||||
24 | appeal under this Section shall be a final administrative | ||||||
25 | decision subject to review under the Administrative Review | ||||||
26 | Law. |
| |||||||
| |||||||
1 | (f-5) Beginning 90 days after July 20, 2012 (the effective | ||||||
2 | date of Public Act 97-842), (i) no denial of a request for | ||||||
3 | approval for payment of non-emergency transportation by means | ||||||
4 | of ground ambulance service, and (ii) no approval of | ||||||
5 | non-emergency transportation by means of ground ambulance | ||||||
6 | service at a level of service that entitles the ground | ||||||
7 | ambulance service provider to a lower level of compensation | ||||||
8 | from the Department than would have been received at the level | ||||||
9 | of service submitted by the ground ambulance service provider, | ||||||
10 | may be issued by the Department or its agent unless the | ||||||
11 | Department has submitted the criteria for determining the | ||||||
12 | appropriateness of the transport for first notice publication | ||||||
13 | in the Illinois Register pursuant to Section 5-40 of the | ||||||
14 | Illinois Administrative Procedure Act. | ||||||
15 | (f-6) Within 90 days after June 2, 2022 ( the effective | ||||||
16 | date of Public Act 102-1037) this amendatory Act of the 102nd | ||||||
17 | General Assembly and subject to federal approval, the | ||||||
18 | Department shall file rules to allow for the approval of | ||||||
19 | ground ambulance services when the sole purpose of the | ||||||
20 | transport is for the navigation of stairs or the assisting or | ||||||
21 | lifting of a patient at a medical facility or during a medical | ||||||
22 | appointment in instances where the Department or a contracted | ||||||
23 | Medicaid managed care organization or their transportation | ||||||
24 | broker is unable to secure transportation through any other | ||||||
25 | transportation provider. | ||||||
26 | (f-7) For non-emergency ground ambulance claims properly |
| |||||||
| |||||||
1 | denied under Department policy at the time the claim is filed | ||||||
2 | due to failure to submit a valid Medical Certification for | ||||||
3 | Non-Emergency Ambulance on and after December 15, 2012 and | ||||||
4 | prior to January 1, 2021, the Department shall allot | ||||||
5 | $2,000,000 to a pool to reimburse such claims if the provider | ||||||
6 | proves medical necessity for the service by other means. | ||||||
7 | Providers must submit any such denied claims for which they | ||||||
8 | seek compensation to the Department no later than December 31, | ||||||
9 | 2021 along with documentation of medical necessity. No later | ||||||
10 | than May 31, 2022, the Department shall determine for which | ||||||
11 | claims medical necessity was established. Such claims for | ||||||
12 | which medical necessity was established shall be paid at the | ||||||
13 | rate in effect at the time of the service, provided the | ||||||
14 | $2,000,000 is sufficient to pay at those rates. If the pool is | ||||||
15 | not sufficient, claims shall be paid at a uniform percentage | ||||||
16 | of the applicable rate such that the pool of $2,000,000 is | ||||||
17 | exhausted. The appeal process described in subsection (f) | ||||||
18 | shall not be applicable to the Department's determinations | ||||||
19 | made in accordance with this subsection. | ||||||
20 | (g) Whenever a patient covered by a medical assistance | ||||||
21 | program under this Code or by another medical program | ||||||
22 | administered by the Department, including a patient covered | ||||||
23 | under the State's Medicaid managed care program, is being | ||||||
24 | transported from a facility and requires non-emergency | ||||||
25 | transportation including ground ambulance, medi-car, or | ||||||
26 | service car transportation, a Physician Certification |
| |||||||
| |||||||
1 | Statement as described in this Section shall be required for | ||||||
2 | each patient. Facilities shall develop procedures for a | ||||||
3 | licensed medical professional to provide a written and signed | ||||||
4 | Physician Certification Statement. The Physician Certification | ||||||
5 | Statement shall specify the level of transportation services | ||||||
6 | needed and complete a medical certification establishing the | ||||||
7 | criteria for approval of non-emergency ambulance | ||||||
8 | transportation, as published by the Department of Healthcare | ||||||
9 | and Family Services, that is met by the patient. This | ||||||
10 | certification shall be completed prior to ordering the | ||||||
11 | transportation service and prior to patient discharge. The | ||||||
12 | Physician Certification Statement is not required prior to | ||||||
13 | transport if a delay in transport can be expected to | ||||||
14 | negatively affect the patient outcome. If the ground ambulance | ||||||
15 | provider, medi-car provider, or service car provider is unable | ||||||
16 | to obtain the required Physician Certification Statement | ||||||
17 | within 10 calendar days following the date of the service, the | ||||||
18 | ground ambulance provider, medi-car provider, or service car | ||||||
19 | provider must document its attempt to obtain the requested | ||||||
20 | certification and may then submit the claim for payment. | ||||||
21 | Acceptable documentation includes a signed return receipt from | ||||||
22 | the U.S. Postal Service, facsimile receipt, email receipt, or | ||||||
23 | other similar service that evidences that the ground ambulance | ||||||
24 | provider, medi-car provider, or service car provider attempted | ||||||
25 | to obtain the required Physician Certification Statement. | ||||||
26 | The medical certification specifying the level and type of |
| |||||||
| |||||||
1 | non-emergency transportation needed shall be in the form of | ||||||
2 | the Physician Certification Statement on a standardized form | ||||||
3 | prescribed by the Department of Healthcare and Family | ||||||
4 | Services. Within 75 days after July 27, 2018 (the effective | ||||||
5 | date of Public Act 100-646), the Department of Healthcare and | ||||||
6 | Family Services shall develop a standardized form of the | ||||||
7 | Physician Certification Statement specifying the level and | ||||||
8 | type of transportation services needed in consultation with | ||||||
9 | the Department of Public Health, Medicaid managed care | ||||||
10 | organizations, a statewide association representing ambulance | ||||||
11 | providers, a statewide association representing hospitals, 3 | ||||||
12 | statewide associations representing nursing homes, and other | ||||||
13 | stakeholders. The Physician Certification Statement shall | ||||||
14 | include, but is not limited to, the criteria necessary to | ||||||
15 | demonstrate medical necessity for the level of transport | ||||||
16 | needed as required by (i) the Department of Healthcare and | ||||||
17 | Family Services and (ii) the federal Centers for Medicare and | ||||||
18 | Medicaid Services as outlined in the Centers for Medicare and | ||||||
19 | Medicaid Services' Medicare Benefit Policy Manual, Pub. | ||||||
20 | 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician | ||||||
21 | Certification Statement shall satisfy the obligations of | ||||||
22 | hospitals under Section 6.22 of the Hospital Licensing Act and | ||||||
23 | nursing homes under Section 2-217 of the Nursing Home Care | ||||||
24 | Act. Implementation and acceptance of the Physician | ||||||
25 | Certification Statement shall take place no later than 90 days | ||||||
26 | after the issuance of the Physician Certification Statement by |
| |||||||
| |||||||
1 | the Department of Healthcare and Family Services. | ||||||
2 | Pursuant to subsection (E) of Section 12-4.25 of this | ||||||
3 | Code, the Department is entitled to recover overpayments paid | ||||||
4 | to a provider or vendor, including, but not limited to, from | ||||||
5 | the discharging physician, the discharging facility, and the | ||||||
6 | ground ambulance service provider, in instances where a | ||||||
7 | non-emergency ground ambulance service is rendered as the | ||||||
8 | result of improper or false certification. | ||||||
9 | Beginning October 1, 2018, the Department of Healthcare | ||||||
10 | and Family Services shall collect data from Medicaid managed | ||||||
11 | care organizations and transportation brokers, including the | ||||||
12 | Department's NETSPAP broker, regarding denials and appeals | ||||||
13 | related to the missing or incomplete Physician Certification | ||||||
14 | Statement forms and overall compliance with this subsection. | ||||||
15 | The Department of Healthcare and Family Services shall publish | ||||||
16 | quarterly results on its website within 15 days following the | ||||||
17 | end of each quarter. | ||||||
18 | (h) On and after July 1, 2012, the Department shall reduce | ||||||
19 | any rate of reimbursement for services or other payments or | ||||||
20 | alter any methodologies authorized by this Code to reduce any | ||||||
21 | rate of reimbursement for services or other payments in | ||||||
22 | accordance with Section 5-5e. | ||||||
23 | (i) Subject to federal approval, on and after January 1, | ||||||
24 | 2024 through June 30, 2026 , the Department shall increase the | ||||||
25 | base rate of reimbursement for both base charges and mileage | ||||||
26 | charges for ground ambulance service providers not |
| |||||||
| |||||||
1 | participating in the Ground Emergency Medical Transportation | ||||||
2 | (GEMT) Program for medical transportation services provided by | ||||||
3 | means of a ground ambulance to a level not lower than 140% of | ||||||
4 | the base rate in effect as of January 1, 2023. | ||||||
5 | (j) For the purpose of understanding ground ambulance | ||||||
6 | transportation services cost structures and their impact on | ||||||
7 | the Medical Assistance Program, the Department shall engage | ||||||
8 | stakeholders, including, but not limited to, a statewide | ||||||
9 | association representing private ground ambulance service | ||||||
10 | providers in Illinois, to develop recommendations for a plan | ||||||
11 | for the regular collection of cost data for all ground | ||||||
12 | ambulance transportation providers reimbursed under the | ||||||
13 | Illinois Title XIX State Plan. Cost data obtained through this | ||||||
14 | process shall be used to inform on and to ensure the | ||||||
15 | effectiveness and efficiency of Illinois Medicaid rates. The | ||||||
16 | Department shall establish a process to limit public | ||||||
17 | availability of portions of the cost report data determined to | ||||||
18 | be proprietary. This process shall be concluded and | ||||||
19 | recommendations shall be provided no later than December 31, | ||||||
20 | 2025 April 1, 2024 . | ||||||
21 | (k) (j) Subject to federal approval, beginning on January | ||||||
22 | 1, 2024, the Department shall increase the base rate of | ||||||
23 | reimbursement for both base charges and mileage charges for | ||||||
24 | medical transportation services provided by means of an air | ||||||
25 | ambulance to a level not lower than 50% of the Medicare | ||||||
26 | ambulance fee schedule rates, by designated Medicare locality, |
| |||||||
| |||||||
1 | in effect on January 1, 2023. | ||||||
2 | (Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; | ||||||
3 | 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article | ||||||
4 | 70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section | ||||||
5 | 80-5, eff. 1-1-24; revised 12-15-23.) | ||||||
6 | ARTICLE 90. | ||||||
7 | Section 90-5. The Illinois Public Aid Code is amended by | ||||||
8 | changing Section 5-5 as follows: | ||||||
9 | (305 ILCS 5/5-5) | ||||||
10 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
11 | rule, shall determine the quantity and quality of and the rate | ||||||
12 | of reimbursement for the medical assistance for which payment | ||||||
13 | will be authorized, and the medical services to be provided, | ||||||
14 | which may include all or part of the following: (1) inpatient | ||||||
15 | hospital services; (2) outpatient hospital services; (3) other | ||||||
16 | laboratory and X-ray services; (4) skilled nursing home | ||||||
17 | services; (5) physicians' services whether furnished in the | ||||||
18 | office, the patient's home, a hospital, a skilled nursing | ||||||
19 | home, or elsewhere; (6) medical care, or any other type of | ||||||
20 | remedial care furnished by licensed practitioners; (7) home | ||||||
21 | health care services; (8) private duty nursing service; (9) | ||||||
22 | clinic services; (10) dental services, including prevention | ||||||
23 | and treatment of periodontal disease and dental caries disease |
| |||||||
| |||||||
1 | for pregnant individuals, provided by an individual licensed | ||||||
2 | to practice dentistry or dental surgery; for purposes of this | ||||||
3 | item (10), "dental services" means diagnostic, preventive, or | ||||||
4 | corrective procedures provided by or under the supervision of | ||||||
5 | a dentist in the practice of his or her profession; (11) | ||||||
6 | physical therapy and related services; (12) prescribed drugs, | ||||||
7 | dentures, and prosthetic devices; and eyeglasses prescribed by | ||||||
8 | a physician skilled in the diseases of the eye, or by an | ||||||
9 | optometrist, whichever the person may select; (13) other | ||||||
10 | diagnostic, screening, preventive, and rehabilitative | ||||||
11 | services, including to ensure that the individual's need for | ||||||
12 | intervention or treatment of mental disorders or substance use | ||||||
13 | disorders or co-occurring mental health and substance use | ||||||
14 | disorders is determined using a uniform screening, assessment, | ||||||
15 | and evaluation process inclusive of criteria, for children and | ||||||
16 | adults; for purposes of this item (13), a uniform screening, | ||||||
17 | assessment, and evaluation process refers to a process that | ||||||
18 | includes an appropriate evaluation and, as warranted, a | ||||||
19 | referral; "uniform" does not mean the use of a singular | ||||||
20 | instrument, tool, or process that all must utilize; (14) | ||||||
21 | transportation and such other expenses as may be necessary; | ||||||
22 | (15) medical treatment of sexual assault survivors, as defined | ||||||
23 | in Section 1a of the Sexual Assault Survivors Emergency | ||||||
24 | Treatment Act, for injuries sustained as a result of the | ||||||
25 | sexual assault, including examinations and laboratory tests to | ||||||
26 | discover evidence which may be used in criminal proceedings |
| |||||||
| |||||||
1 | arising from the sexual assault; (16) the diagnosis and | ||||||
2 | treatment of sickle cell anemia; (16.5) services performed by | ||||||
3 | a chiropractic physician licensed under the Medical Practice | ||||||
4 | Act of 1987 and acting within the scope of his or her license, | ||||||
5 | including, but not limited to, chiropractic manipulative | ||||||
6 | treatment; and (17) any other medical care, and any other type | ||||||
7 | of remedial care recognized under the laws of this State. The | ||||||
8 | term "any other type of remedial care" shall include nursing | ||||||
9 | care and nursing home service for persons who rely on | ||||||
10 | treatment by spiritual means alone through prayer for healing. | ||||||
11 | Notwithstanding any other provision of this Section, a | ||||||
12 | comprehensive tobacco use cessation program that includes | ||||||
13 | purchasing prescription drugs or prescription medical devices | ||||||
14 | approved by the Food and Drug Administration shall be covered | ||||||
15 | under the medical assistance program under this Article for | ||||||
16 | persons who are otherwise eligible for assistance under this | ||||||
17 | Article. | ||||||
18 | Notwithstanding any other provision of this Code, | ||||||
19 | reproductive health care that is otherwise legal in Illinois | ||||||
20 | shall be covered under the medical assistance program for | ||||||
21 | persons who are otherwise eligible for medical assistance | ||||||
22 | under this Article. | ||||||
23 | Notwithstanding any other provision of this Section, all | ||||||
24 | tobacco cessation medications approved by the United States | ||||||
25 | Food and Drug Administration and all individual and group | ||||||
26 | tobacco cessation counseling services and telephone-based |
| |||||||
| |||||||
1 | counseling services and tobacco cessation medications provided | ||||||
2 | through the Illinois Tobacco Quitline shall be covered under | ||||||
3 | the medical assistance program for persons who are otherwise | ||||||
4 | eligible for assistance under this Article. The Department | ||||||
5 | shall comply with all federal requirements necessary to obtain | ||||||
6 | federal financial participation, as specified in 42 CFR | ||||||
7 | 433.15(b)(7), for telephone-based counseling services provided | ||||||
8 | through the Illinois Tobacco Quitline, including, but not | ||||||
9 | limited to: (i) entering into a memorandum of understanding or | ||||||
10 | interagency agreement with the Department of Public Health, as | ||||||
11 | administrator of the Illinois Tobacco Quitline; and (ii) | ||||||
12 | developing a cost allocation plan for Medicaid-allowable | ||||||
13 | Illinois Tobacco Quitline services in accordance with 45 CFR | ||||||
14 | 95.507. The Department shall submit the memorandum of | ||||||
15 | understanding or interagency agreement, the cost allocation | ||||||
16 | plan, and all other necessary documentation to the Centers for | ||||||
17 | Medicare and Medicaid Services for review and approval. | ||||||
18 | Coverage under this paragraph shall be contingent upon federal | ||||||
19 | approval. | ||||||
20 | Notwithstanding any other provision of this Code, the | ||||||
21 | Illinois Department may not require, as a condition of payment | ||||||
22 | for any laboratory test authorized under this Article, that a | ||||||
23 | physician's handwritten signature appear on the laboratory | ||||||
24 | test order form. The Illinois Department may, however, impose | ||||||
25 | other appropriate requirements regarding laboratory test order | ||||||
26 | documentation. |
| |||||||
| |||||||
1 | Upon receipt of federal approval of an amendment to the | ||||||
2 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
3 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
4 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
5 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
6 | that its vendor or vendors are enrolled as providers in the | ||||||
7 | medical assistance program and in any capitated Medicaid | ||||||
8 | managed care entity (MCE) serving individuals enrolled in a | ||||||
9 | school within the CPS system. Under any contract procured | ||||||
10 | under this provision, the vendor or vendors must serve only | ||||||
11 | individuals enrolled in a school within the CPS system. Claims | ||||||
12 | for services provided by CPS's vendor or vendors to recipients | ||||||
13 | of benefits in the medical assistance program under this Code, | ||||||
14 | the Children's Health Insurance Program, or the Covering ALL | ||||||
15 | KIDS Health Insurance Program shall be submitted to the | ||||||
16 | Department or the MCE in which the individual is enrolled for | ||||||
17 | payment and shall be reimbursed at the Department's or the | ||||||
18 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
19 | On and after July 1, 2012, the Department of Healthcare | ||||||
20 | and Family Services may provide the following services to | ||||||
21 | persons eligible for assistance under this Article who are | ||||||
22 | participating in education, training or employment programs | ||||||
23 | operated by the Department of Human Services as successor to | ||||||
24 | the Department of Public Aid: | ||||||
25 | (1) dental services provided by or under the | ||||||
26 | supervision of a dentist; and |
| |||||||
| |||||||
1 | (2) eyeglasses prescribed by a physician skilled in | ||||||
2 | the diseases of the eye, or by an optometrist, whichever | ||||||
3 | the person may select. | ||||||
4 | On and after July 1, 2018, the Department of Healthcare | ||||||
5 | and Family Services shall provide dental services to any adult | ||||||
6 | who is otherwise eligible for assistance under the medical | ||||||
7 | assistance program. As used in this paragraph, "dental | ||||||
8 | services" means diagnostic, preventative, restorative, or | ||||||
9 | corrective procedures, including procedures and services for | ||||||
10 | the prevention and treatment of periodontal disease and dental | ||||||
11 | caries disease, provided by an individual who is licensed to | ||||||
12 | practice dentistry or dental surgery or who is under the | ||||||
13 | supervision of a dentist in the practice of his or her | ||||||
14 | profession. | ||||||
15 | On and after July 1, 2018, targeted dental services, as | ||||||
16 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
17 | United States District Court for the Northern District of | ||||||
18 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
19 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
20 | the medical assistance program shall be established at no less | ||||||
21 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
22 | of the Consent Decree for targeted dental services that are | ||||||
23 | provided to persons under the age of 18 under the medical | ||||||
24 | assistance program. | ||||||
25 | Notwithstanding any other provision of this Code and | ||||||
26 | subject to federal approval, the Department may adopt rules to |
| |||||||
| |||||||
1 | allow a dentist who is volunteering his or her service at no | ||||||
2 | cost to render dental services through an enrolled | ||||||
3 | not-for-profit health clinic without the dentist personally | ||||||
4 | enrolling as a participating provider in the medical | ||||||
5 | assistance program. A not-for-profit health clinic shall | ||||||
6 | include a public health clinic or Federally Qualified Health | ||||||
7 | Center or other enrolled provider, as determined by the | ||||||
8 | Department, through which dental services covered under this | ||||||
9 | Section are performed. The Department shall establish a | ||||||
10 | process for payment of claims for reimbursement for covered | ||||||
11 | dental services rendered under this provision. | ||||||
12 | Subject to appropriation and to federal approval, the | ||||||
13 | Department shall file administrative rules updating the | ||||||
14 | Handicapping Labio-Lingual Deviation orthodontic scoring tool | ||||||
15 | by January 1, 2025, or as soon as practicable. | ||||||
16 | On and after January 1, 2022, the Department of Healthcare | ||||||
17 | and Family Services shall administer and regulate a | ||||||
18 | school-based dental program that allows for the out-of-office | ||||||
19 | delivery of preventative dental services in a school setting | ||||||
20 | to children under 19 years of age. The Department shall | ||||||
21 | establish, by rule, guidelines for participation by providers | ||||||
22 | and set requirements for follow-up referral care based on the | ||||||
23 | requirements established in the Dental Office Reference Manual | ||||||
24 | published by the Department that establishes the requirements | ||||||
25 | for dentists participating in the All Kids Dental School | ||||||
26 | Program. Every effort shall be made by the Department when |
| |||||||
| |||||||
1 | developing the program requirements to consider the different | ||||||
2 | geographic differences of both urban and rural areas of the | ||||||
3 | State for initial treatment and necessary follow-up care. No | ||||||
4 | provider shall be charged a fee by any unit of local government | ||||||
5 | to participate in the school-based dental program administered | ||||||
6 | by the Department. Nothing in this paragraph shall be | ||||||
7 | construed to limit or preempt a home rule unit's or school | ||||||
8 | district's authority to establish, change, or administer a | ||||||
9 | school-based dental program in addition to, or independent of, | ||||||
10 | the school-based dental program administered by the | ||||||
11 | Department. | ||||||
12 | The Illinois Department, by rule, may distinguish and | ||||||
13 | classify the medical services to be provided only in | ||||||
14 | accordance with the classes of persons designated in Section | ||||||
15 | 5-2. | ||||||
16 | The Department of Healthcare and Family Services must | ||||||
17 | provide coverage and reimbursement for amino acid-based | ||||||
18 | elemental formulas, regardless of delivery method, for the | ||||||
19 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
20 | short bowel syndrome when the prescribing physician has issued | ||||||
21 | a written order stating that the amino acid-based elemental | ||||||
22 | formula is medically necessary. | ||||||
23 | The Illinois Department shall authorize the provision of, | ||||||
24 | and shall authorize payment for, screening by low-dose | ||||||
25 | mammography for the presence of occult breast cancer for | ||||||
26 | individuals 35 years of age or older who are eligible for |
| |||||||
| |||||||
1 | medical assistance under this Article, as follows: | ||||||
2 | (A) A baseline mammogram for individuals 35 to 39 | ||||||
3 | years of age. | ||||||
4 | (B) An annual mammogram for individuals 40 years of | ||||||
5 | age or older. | ||||||
6 | (C) A mammogram at the age and intervals considered | ||||||
7 | medically necessary by the individual's health care | ||||||
8 | provider for individuals under 40 years of age and having | ||||||
9 | a family history of breast cancer, prior personal history | ||||||
10 | of breast cancer, positive genetic testing, or other risk | ||||||
11 | factors. | ||||||
12 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
13 | entire breast or breasts if a mammogram demonstrates | ||||||
14 | heterogeneous or dense breast tissue or when medically | ||||||
15 | necessary as determined by a physician licensed to | ||||||
16 | practice medicine in all of its branches. | ||||||
17 | (E) A screening MRI when medically necessary, as | ||||||
18 | determined by a physician licensed to practice medicine in | ||||||
19 | all of its branches. | ||||||
20 | (F) A diagnostic mammogram when medically necessary, | ||||||
21 | as determined by a physician licensed to practice medicine | ||||||
22 | in all its branches, advanced practice registered nurse, | ||||||
23 | or physician assistant. | ||||||
24 | The Department shall not impose a deductible, coinsurance, | ||||||
25 | copayment, or any other cost-sharing requirement on the | ||||||
26 | coverage provided under this paragraph; except that this |
| |||||||
| |||||||
1 | sentence does not apply to coverage of diagnostic mammograms | ||||||
2 | to the extent such coverage would disqualify a high-deductible | ||||||
3 | health plan from eligibility for a health savings account | ||||||
4 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
5 | U.S.C. 223). | ||||||
6 | All screenings shall include a physical breast exam, | ||||||
7 | instruction on self-examination and information regarding the | ||||||
8 | frequency of self-examination and its value as a preventative | ||||||
9 | tool. | ||||||
10 | For purposes of this Section: | ||||||
11 | "Diagnostic mammogram" means a mammogram obtained using | ||||||
12 | diagnostic mammography. | ||||||
13 | "Diagnostic mammography" means a method of screening that | ||||||
14 | is designed to evaluate an abnormality in a breast, including | ||||||
15 | an abnormality seen or suspected on a screening mammogram or a | ||||||
16 | subjective or objective abnormality otherwise detected in the | ||||||
17 | breast. | ||||||
18 | "Low-dose mammography" means the x-ray examination of the | ||||||
19 | breast using equipment dedicated specifically for mammography, | ||||||
20 | including the x-ray tube, filter, compression device, and | ||||||
21 | image receptor, with an average radiation exposure delivery of | ||||||
22 | less than one rad per breast for 2 views of an average size | ||||||
23 | breast. The term also includes digital mammography and | ||||||
24 | includes breast tomosynthesis. | ||||||
25 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
26 | involves the acquisition of projection images over the |
| |||||||
| |||||||
1 | stationary breast to produce cross-sectional digital | ||||||
2 | three-dimensional images of the breast. | ||||||
3 | If, at any time, the Secretary of the United States | ||||||
4 | Department of Health and Human Services, or its successor | ||||||
5 | agency, promulgates rules or regulations to be published in | ||||||
6 | the Federal Register or publishes a comment in the Federal | ||||||
7 | Register or issues an opinion, guidance, or other action that | ||||||
8 | would require the State, pursuant to any provision of the | ||||||
9 | Patient Protection and Affordable Care Act (Public Law | ||||||
10 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
11 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
12 | of any coverage for breast tomosynthesis outlined in this | ||||||
13 | paragraph, then the requirement that an insurer cover breast | ||||||
14 | tomosynthesis is inoperative other than any such coverage | ||||||
15 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
16 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
17 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
18 | this paragraph. | ||||||
19 | On and after January 1, 2016, the Department shall ensure | ||||||
20 | that all networks of care for adult clients of the Department | ||||||
21 | include access to at least one breast imaging Center of | ||||||
22 | Imaging Excellence as certified by the American College of | ||||||
23 | Radiology. | ||||||
24 | On and after January 1, 2012, providers participating in a | ||||||
25 | quality improvement program approved by the Department shall | ||||||
26 | be reimbursed for screening and diagnostic mammography at the |
| |||||||
| |||||||
1 | same rate as the Medicare program's rates, including the | ||||||
2 | increased reimbursement for digital mammography and, after | ||||||
3 | January 1, 2023 (the effective date of Public Act 102-1018), | ||||||
4 | breast tomosynthesis. | ||||||
5 | The Department shall convene an expert panel including | ||||||
6 | representatives of hospitals, free-standing mammography | ||||||
7 | facilities, and doctors, including radiologists, to establish | ||||||
8 | quality standards for mammography. | ||||||
9 | On and after January 1, 2017, providers participating in a | ||||||
10 | breast cancer treatment quality improvement program approved | ||||||
11 | by the Department shall be reimbursed for breast cancer | ||||||
12 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
13 | program's rates for the data elements included in the breast | ||||||
14 | cancer treatment quality program. | ||||||
15 | The Department shall convene an expert panel, including | ||||||
16 | representatives of hospitals, free-standing breast cancer | ||||||
17 | treatment centers, breast cancer quality organizations, and | ||||||
18 | doctors, including breast surgeons, reconstructive breast | ||||||
19 | surgeons, oncologists, and primary care providers to establish | ||||||
20 | quality standards for breast cancer treatment. | ||||||
21 | Subject to federal approval, the Department shall | ||||||
22 | establish a rate methodology for mammography at federally | ||||||
23 | qualified health centers and other encounter-rate clinics. | ||||||
24 | These clinics or centers may also collaborate with other | ||||||
25 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
26 | Department shall report to the General Assembly on the status |
| |||||||
| |||||||
1 | of the provision set forth in this paragraph. | ||||||
2 | The Department shall establish a methodology to remind | ||||||
3 | individuals who are age-appropriate for screening mammography, | ||||||
4 | but who have not received a mammogram within the previous 18 | ||||||
5 | months, of the importance and benefit of screening | ||||||
6 | mammography. The Department shall work with experts in breast | ||||||
7 | cancer outreach and patient navigation to optimize these | ||||||
8 | reminders and shall establish a methodology for evaluating | ||||||
9 | their effectiveness and modifying the methodology based on the | ||||||
10 | evaluation. | ||||||
11 | The Department shall establish a performance goal for | ||||||
12 | primary care providers with respect to their female patients | ||||||
13 | over age 40 receiving an annual mammogram. This performance | ||||||
14 | goal shall be used to provide additional reimbursement in the | ||||||
15 | form of a quality performance bonus to primary care providers | ||||||
16 | who meet that goal. | ||||||
17 | The Department shall devise a means of case-managing or | ||||||
18 | patient navigation for beneficiaries diagnosed with breast | ||||||
19 | cancer. This program shall initially operate as a pilot | ||||||
20 | program in areas of the State with the highest incidence of | ||||||
21 | mortality related to breast cancer. At least one pilot program | ||||||
22 | site shall be in the metropolitan Chicago area and at least one | ||||||
23 | site shall be outside the metropolitan Chicago area. On or | ||||||
24 | after July 1, 2016, the pilot program shall be expanded to | ||||||
25 | include one site in western Illinois, one site in southern | ||||||
26 | Illinois, one site in central Illinois, and 4 sites within |
| |||||||
| |||||||
1 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
2 | be carried out measuring health outcomes and cost of care for | ||||||
3 | those served by the pilot program compared to similarly | ||||||
4 | situated patients who are not served by the pilot program. | ||||||
5 | The Department shall require all networks of care to | ||||||
6 | develop a means either internally or by contract with experts | ||||||
7 | in navigation and community outreach to navigate cancer | ||||||
8 | patients to comprehensive care in a timely fashion. The | ||||||
9 | Department shall require all networks of care to include | ||||||
10 | access for patients diagnosed with cancer to at least one | ||||||
11 | academic commission on cancer-accredited cancer program as an | ||||||
12 | in-network covered benefit. | ||||||
13 | The Department shall provide coverage and reimbursement | ||||||
14 | for a human papillomavirus (HPV) vaccine that is approved for | ||||||
15 | marketing by the federal Food and Drug Administration for all | ||||||
16 | persons between the ages of 9 and 45. Subject to federal | ||||||
17 | approval, the Department shall provide coverage and | ||||||
18 | reimbursement for a human papillomavirus (HPV) vaccine for | ||||||
19 | persons of the age of 46 and above who have been diagnosed with | ||||||
20 | cervical dysplasia with a high risk of recurrence or | ||||||
21 | progression. The Department shall disallow any | ||||||
22 | preauthorization requirements for the administration of the | ||||||
23 | human papillomavirus (HPV) vaccine. | ||||||
24 | On or after July 1, 2022, individuals who are otherwise | ||||||
25 | eligible for medical assistance under this Article shall | ||||||
26 | receive coverage for perinatal depression screenings for the |
| |||||||
| |||||||
1 | 12-month period beginning on the last day of their pregnancy. | ||||||
2 | Medical assistance coverage under this paragraph shall be | ||||||
3 | conditioned on the use of a screening instrument approved by | ||||||
4 | the Department. | ||||||
5 | Any medical or health care provider shall immediately | ||||||
6 | recommend, to any pregnant individual who is being provided | ||||||
7 | prenatal services and is suspected of having a substance use | ||||||
8 | disorder as defined in the Substance Use Disorder Act, | ||||||
9 | referral to a local substance use disorder treatment program | ||||||
10 | licensed by the Department of Human Services or to a licensed | ||||||
11 | hospital which provides substance abuse treatment services. | ||||||
12 | The Department of Healthcare and Family Services shall assure | ||||||
13 | coverage for the cost of treatment of the drug abuse or | ||||||
14 | addiction for pregnant recipients in accordance with the | ||||||
15 | Illinois Medicaid Program in conjunction with the Department | ||||||
16 | of Human Services. | ||||||
17 | All medical providers providing medical assistance to | ||||||
18 | pregnant individuals under this Code shall receive information | ||||||
19 | from the Department on the availability of services under any | ||||||
20 | program providing case management services for addicted | ||||||
21 | individuals, including information on appropriate referrals | ||||||
22 | for other social services that may be needed by addicted | ||||||
23 | individuals in addition to treatment for addiction. | ||||||
24 | The Illinois Department, in cooperation with the | ||||||
25 | Departments of Human Services (as successor to the Department | ||||||
26 | of Alcoholism and Substance Abuse) and Public Health, through |
| |||||||
| |||||||
1 | a public awareness campaign, may provide information | ||||||
2 | concerning treatment for alcoholism and drug abuse and | ||||||
3 | addiction, prenatal health care, and other pertinent programs | ||||||
4 | directed at reducing the number of drug-affected infants born | ||||||
5 | to recipients of medical assistance. | ||||||
6 | Neither the Department of Healthcare and Family Services | ||||||
7 | nor the Department of Human Services shall sanction the | ||||||
8 | recipient solely on the basis of the recipient's substance | ||||||
9 | abuse. | ||||||
10 | The Illinois Department shall establish such regulations | ||||||
11 | governing the dispensing of health services under this Article | ||||||
12 | as it shall deem appropriate. The Department should seek the | ||||||
13 | advice of formal professional advisory committees appointed by | ||||||
14 | the Director of the Illinois Department for the purpose of | ||||||
15 | providing regular advice on policy and administrative matters, | ||||||
16 | information dissemination and educational activities for | ||||||
17 | medical and health care providers, and consistency in | ||||||
18 | procedures to the Illinois Department. | ||||||
19 | The Illinois Department may develop and contract with | ||||||
20 | Partnerships of medical providers to arrange medical services | ||||||
21 | for persons eligible under Section 5-2 of this Code. | ||||||
22 | Implementation of this Section may be by demonstration | ||||||
23 | projects in certain geographic areas. The Partnership shall be | ||||||
24 | represented by a sponsor organization. The Department, by | ||||||
25 | rule, shall develop qualifications for sponsors of | ||||||
26 | Partnerships. Nothing in this Section shall be construed to |
| |||||||
| |||||||
1 | require that the sponsor organization be a medical | ||||||
2 | organization. | ||||||
3 | The sponsor must negotiate formal written contracts with | ||||||
4 | medical providers for physician services, inpatient and | ||||||
5 | outpatient hospital care, home health services, treatment for | ||||||
6 | alcoholism and substance abuse, and other services determined | ||||||
7 | necessary by the Illinois Department by rule for delivery by | ||||||
8 | Partnerships. Physician services must include prenatal and | ||||||
9 | obstetrical care. The Illinois Department shall reimburse | ||||||
10 | medical services delivered by Partnership providers to clients | ||||||
11 | in target areas according to provisions of this Article and | ||||||
12 | the Illinois Health Finance Reform Act, except that: | ||||||
13 | (1) Physicians participating in a Partnership and | ||||||
14 | providing certain services, which shall be determined by | ||||||
15 | the Illinois Department, to persons in areas covered by | ||||||
16 | the Partnership may receive an additional surcharge for | ||||||
17 | such services. | ||||||
18 | (2) The Department may elect to consider and negotiate | ||||||
19 | financial incentives to encourage the development of | ||||||
20 | Partnerships and the efficient delivery of medical care. | ||||||
21 | (3) Persons receiving medical services through | ||||||
22 | Partnerships may receive medical and case management | ||||||
23 | services above the level usually offered through the | ||||||
24 | medical assistance program. | ||||||
25 | Medical providers shall be required to meet certain | ||||||
26 | qualifications to participate in Partnerships to ensure the |
| |||||||
| |||||||
1 | delivery of high quality medical services. These | ||||||
2 | qualifications shall be determined by rule of the Illinois | ||||||
3 | Department and may be higher than qualifications for | ||||||
4 | participation in the medical assistance program. Partnership | ||||||
5 | sponsors may prescribe reasonable additional qualifications | ||||||
6 | for participation by medical providers, only with the prior | ||||||
7 | written approval of the Illinois Department. | ||||||
8 | Nothing in this Section shall limit the free choice of | ||||||
9 | practitioners, hospitals, and other providers of medical | ||||||
10 | services by clients. In order to ensure patient freedom of | ||||||
11 | choice, the Illinois Department shall immediately promulgate | ||||||
12 | all rules and take all other necessary actions so that | ||||||
13 | provided services may be accessed from therapeutically | ||||||
14 | certified optometrists to the full extent of the Illinois | ||||||
15 | Optometric Practice Act of 1987 without discriminating between | ||||||
16 | service providers. | ||||||
17 | The Department shall apply for a waiver from the United | ||||||
18 | States Health Care Financing Administration to allow for the | ||||||
19 | implementation of Partnerships under this Section. | ||||||
20 | The Illinois Department shall require health care | ||||||
21 | providers to maintain records that document the medical care | ||||||
22 | and services provided to recipients of Medical Assistance | ||||||
23 | under this Article. Such records must be retained for a period | ||||||
24 | of not less than 6 years from the date of service or as | ||||||
25 | provided by applicable State law, whichever period is longer, | ||||||
26 | except that if an audit is initiated within the required |
| |||||||
| |||||||
1 | retention period then the records must be retained until the | ||||||
2 | audit is completed and every exception is resolved. The | ||||||
3 | Illinois Department shall require health care providers to | ||||||
4 | make available, when authorized by the patient, in writing, | ||||||
5 | the medical records in a timely fashion to other health care | ||||||
6 | providers who are treating or serving persons eligible for | ||||||
7 | Medical Assistance under this Article. All dispensers of | ||||||
8 | medical services shall be required to maintain and retain | ||||||
9 | business and professional records sufficient to fully and | ||||||
10 | accurately document the nature, scope, details and receipt of | ||||||
11 | the health care provided to persons eligible for medical | ||||||
12 | assistance under this Code, in accordance with regulations | ||||||
13 | promulgated by the Illinois Department. The rules and | ||||||
14 | regulations shall require that proof of the receipt of | ||||||
15 | prescription drugs, dentures, prosthetic devices and | ||||||
16 | eyeglasses by eligible persons under this Section accompany | ||||||
17 | each claim for reimbursement submitted by the dispenser of | ||||||
18 | such medical services. No such claims for reimbursement shall | ||||||
19 | be approved for payment by the Illinois Department without | ||||||
20 | such proof of receipt, unless the Illinois Department shall | ||||||
21 | have put into effect and shall be operating a system of | ||||||
22 | post-payment audit and review which shall, on a sampling | ||||||
23 | basis, be deemed adequate by the Illinois Department to assure | ||||||
24 | that such drugs, dentures, prosthetic devices and eyeglasses | ||||||
25 | for which payment is being made are actually being received by | ||||||
26 | eligible recipients. Within 90 days after September 16, 1984 |
| |||||||
| |||||||
1 | (the effective date of Public Act 83-1439), the Illinois | ||||||
2 | Department shall establish a current list of acquisition costs | ||||||
3 | for all prosthetic devices and any other items recognized as | ||||||
4 | medical equipment and supplies reimbursable under this Article | ||||||
5 | and shall update such list on a quarterly basis, except that | ||||||
6 | the acquisition costs of all prescription drugs shall be | ||||||
7 | updated no less frequently than every 30 days as required by | ||||||
8 | Section 5-5.12. | ||||||
9 | Notwithstanding any other law to the contrary, the | ||||||
10 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
11 | (the effective date of Public Act 98-104), establish | ||||||
12 | procedures to permit skilled care facilities licensed under | ||||||
13 | the Nursing Home Care Act to submit monthly billing claims for | ||||||
14 | reimbursement purposes. Following development of these | ||||||
15 | procedures, the Department shall, by July 1, 2016, test the | ||||||
16 | viability of the new system and implement any necessary | ||||||
17 | operational or structural changes to its information | ||||||
18 | technology platforms in order to allow for the direct | ||||||
19 | acceptance and payment of nursing home claims. | ||||||
20 | Notwithstanding any other law to the contrary, the | ||||||
21 | Illinois Department shall, within 365 days after August 15, | ||||||
22 | 2014 (the effective date of Public Act 98-963), establish | ||||||
23 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
24 | Community Care Act and MC/DD facilities licensed under the | ||||||
25 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
26 | purposes. Following development of these procedures, the |
| |||||||
| |||||||
1 | Department shall have an additional 365 days to test the | ||||||
2 | viability of the new system and to ensure that any necessary | ||||||
3 | operational or structural changes to its information | ||||||
4 | technology platforms are implemented. | ||||||
5 | The Illinois Department shall require all dispensers of | ||||||
6 | medical services, other than an individual practitioner or | ||||||
7 | group of practitioners, desiring to participate in the Medical | ||||||
8 | Assistance program established under this Article to disclose | ||||||
9 | all financial, beneficial, ownership, equity, surety or other | ||||||
10 | interests in any and all firms, corporations, partnerships, | ||||||
11 | associations, business enterprises, joint ventures, agencies, | ||||||
12 | institutions or other legal entities providing any form of | ||||||
13 | health care services in this State under this Article. | ||||||
14 | The Illinois Department may require that all dispensers of | ||||||
15 | medical services desiring to participate in the medical | ||||||
16 | assistance program established under this Article disclose, | ||||||
17 | under such terms and conditions as the Illinois Department may | ||||||
18 | by rule establish, all inquiries from clients and attorneys | ||||||
19 | regarding medical bills paid by the Illinois Department, which | ||||||
20 | inquiries could indicate potential existence of claims or | ||||||
21 | liens for the Illinois Department. | ||||||
22 | Enrollment of a vendor shall be subject to a provisional | ||||||
23 | period and shall be conditional for one year. During the | ||||||
24 | period of conditional enrollment, the Department may terminate | ||||||
25 | the vendor's eligibility to participate in, or may disenroll | ||||||
26 | the vendor from, the medical assistance program without cause. |
| |||||||
| |||||||
1 | Unless otherwise specified, such termination of eligibility or | ||||||
2 | disenrollment is not subject to the Department's hearing | ||||||
3 | process. However, a disenrolled vendor may reapply without | ||||||
4 | penalty. | ||||||
5 | The Department has the discretion to limit the conditional | ||||||
6 | enrollment period for vendors based upon the category of risk | ||||||
7 | of the vendor. | ||||||
8 | Prior to enrollment and during the conditional enrollment | ||||||
9 | period in the medical assistance program, all vendors shall be | ||||||
10 | subject to enhanced oversight, screening, and review based on | ||||||
11 | the risk of fraud, waste, and abuse that is posed by the | ||||||
12 | category of risk of the vendor. The Illinois Department shall | ||||||
13 | establish the procedures for oversight, screening, and review, | ||||||
14 | which may include, but need not be limited to: criminal and | ||||||
15 | financial background checks; fingerprinting; license, | ||||||
16 | certification, and authorization verifications; unscheduled or | ||||||
17 | unannounced site visits; database checks; prepayment audit | ||||||
18 | reviews; audits; payment caps; payment suspensions; and other | ||||||
19 | screening as required by federal or State law. | ||||||
20 | The Department shall define or specify the following: (i) | ||||||
21 | by provider notice, the "category of risk of the vendor" for | ||||||
22 | each type of vendor, which shall take into account the level of | ||||||
23 | screening applicable to a particular category of vendor under | ||||||
24 | federal law and regulations; (ii) by rule or provider notice, | ||||||
25 | the maximum length of the conditional enrollment period for | ||||||
26 | each category of risk of the vendor; and (iii) by rule, the |
| |||||||
| |||||||
1 | hearing rights, if any, afforded to a vendor in each category | ||||||
2 | of risk of the vendor that is terminated or disenrolled during | ||||||
3 | the conditional enrollment period. | ||||||
4 | To be eligible for payment consideration, a vendor's | ||||||
5 | payment claim or bill, either as an initial claim or as a | ||||||
6 | resubmitted claim following prior rejection, must be received | ||||||
7 | by the Illinois Department, or its fiscal intermediary, no | ||||||
8 | later than 180 days after the latest date on the claim on which | ||||||
9 | medical goods or services were provided, with the following | ||||||
10 | exceptions: | ||||||
11 | (1) In the case of a provider whose enrollment is in | ||||||
12 | process by the Illinois Department, the 180-day period | ||||||
13 | shall not begin until the date on the written notice from | ||||||
14 | the Illinois Department that the provider enrollment is | ||||||
15 | complete. | ||||||
16 | (2) In the case of errors attributable to the Illinois | ||||||
17 | Department or any of its claims processing intermediaries | ||||||
18 | which result in an inability to receive, process, or | ||||||
19 | adjudicate a claim, the 180-day period shall not begin | ||||||
20 | until the provider has been notified of the error. | ||||||
21 | (3) In the case of a provider for whom the Illinois | ||||||
22 | Department initiates the monthly billing process. | ||||||
23 | (4) In the case of a provider operated by a unit of | ||||||
24 | local government with a population exceeding 3,000,000 | ||||||
25 | when local government funds finance federal participation | ||||||
26 | for claims payments. |
| |||||||
| |||||||
1 | For claims for services rendered during a period for which | ||||||
2 | a recipient received retroactive eligibility, claims must be | ||||||
3 | filed within 180 days after the Department determines the | ||||||
4 | applicant is eligible. For claims for which the Illinois | ||||||
5 | Department is not the primary payer, claims must be submitted | ||||||
6 | to the Illinois Department within 180 days after the final | ||||||
7 | adjudication by the primary payer. | ||||||
8 | In the case of long term care facilities, within 120 | ||||||
9 | calendar days of receipt by the facility of required | ||||||
10 | prescreening information, new admissions with associated | ||||||
11 | admission documents shall be submitted through the Medical | ||||||
12 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
13 | Eligibility Verification (REV) System or shall be submitted | ||||||
14 | directly to the Department of Human Services using required | ||||||
15 | admission forms. Effective September 1, 2014, admission | ||||||
16 | documents, including all prescreening information, must be | ||||||
17 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
18 | to an accepted transaction shall be retained by a facility to | ||||||
19 | verify timely submittal. Once an admission transaction has | ||||||
20 | been completed, all resubmitted claims following prior | ||||||
21 | rejection are subject to receipt no later than 180 days after | ||||||
22 | the admission transaction has been completed. | ||||||
23 | Claims that are not submitted and received in compliance | ||||||
24 | with the foregoing requirements shall not be eligible for | ||||||
25 | payment under the medical assistance program, and the State | ||||||
26 | shall have no liability for payment of those claims. |
| |||||||
| |||||||
1 | To the extent consistent with applicable information and | ||||||
2 | privacy, security, and disclosure laws, State and federal | ||||||
3 | agencies and departments shall provide the Illinois Department | ||||||
4 | access to confidential and other information and data | ||||||
5 | necessary to perform eligibility and payment verifications and | ||||||
6 | other Illinois Department functions. This includes, but is not | ||||||
7 | limited to: information pertaining to licensure; | ||||||
8 | certification; earnings; immigration status; citizenship; wage | ||||||
9 | reporting; unearned and earned income; pension income; | ||||||
10 | employment; supplemental security income; social security | ||||||
11 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
12 | National Practitioner Data Bank (NPDB); program and agency | ||||||
13 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
14 | corporate information; and death records. | ||||||
15 | The Illinois Department shall enter into agreements with | ||||||
16 | State agencies and departments, and is authorized to enter | ||||||
17 | into agreements with federal agencies and departments, under | ||||||
18 | which such agencies and departments shall share data necessary | ||||||
19 | for medical assistance program integrity functions and | ||||||
20 | oversight. The Illinois Department shall develop, in | ||||||
21 | cooperation with other State departments and agencies, and in | ||||||
22 | compliance with applicable federal laws and regulations, | ||||||
23 | appropriate and effective methods to share such data. At a | ||||||
24 | minimum, and to the extent necessary to provide data sharing, | ||||||
25 | the Illinois Department shall enter into agreements with State | ||||||
26 | agencies and departments, and is authorized to enter into |
| |||||||
| |||||||
1 | agreements with federal agencies and departments, including, | ||||||
2 | but not limited to: the Secretary of State; the Department of | ||||||
3 | Revenue; the Department of Public Health; the Department of | ||||||
4 | Human Services; and the Department of Financial and | ||||||
5 | Professional Regulation. | ||||||
6 | Beginning in fiscal year 2013, the Illinois Department | ||||||
7 | shall set forth a request for information to identify the | ||||||
8 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
9 | claims system with the goals of streamlining claims processing | ||||||
10 | and provider reimbursement, reducing the number of pending or | ||||||
11 | rejected claims, and helping to ensure a more transparent | ||||||
12 | adjudication process through the utilization of: (i) provider | ||||||
13 | data verification and provider screening technology; and (ii) | ||||||
14 | clinical code editing; and (iii) pre-pay, pre-adjudicated , or | ||||||
15 | post-adjudicated predictive modeling with an integrated case | ||||||
16 | management system with link analysis. Such a request for | ||||||
17 | information shall not be considered as a request for proposal | ||||||
18 | or as an obligation on the part of the Illinois Department to | ||||||
19 | take any action or acquire any products or services. | ||||||
20 | The Illinois Department shall establish policies, | ||||||
21 | procedures, standards and criteria by rule for the | ||||||
22 | acquisition, repair and replacement of orthotic and prosthetic | ||||||
23 | devices and durable medical equipment. Such rules shall | ||||||
24 | provide, but not be limited to, the following services: (1) | ||||||
25 | immediate repair or replacement of such devices by recipients; | ||||||
26 | and (2) rental, lease, purchase or lease-purchase of durable |
| |||||||
| |||||||
1 | medical equipment in a cost-effective manner, taking into | ||||||
2 | consideration the recipient's medical prognosis, the extent of | ||||||
3 | the recipient's needs, and the requirements and costs for | ||||||
4 | maintaining such equipment. Subject to prior approval, such | ||||||
5 | rules shall enable a recipient to temporarily acquire and use | ||||||
6 | alternative or substitute devices or equipment pending repairs | ||||||
7 | or replacements of any device or equipment previously | ||||||
8 | authorized for such recipient by the Department. | ||||||
9 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
10 | the Department may, by rule, exempt certain replacement | ||||||
11 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
12 | wheelchair parts, wheelchair accessories, and related seating | ||||||
13 | and positioning items, determine the wholesale price by | ||||||
14 | methods other than actual acquisition costs. | ||||||
15 | The Department shall require, by rule, all providers of | ||||||
16 | durable medical equipment to be accredited by an accreditation | ||||||
17 | organization approved by the federal Centers for Medicare and | ||||||
18 | Medicaid Services and recognized by the Department in order to | ||||||
19 | bill the Department for providing durable medical equipment to | ||||||
20 | recipients. No later than 15 months after the effective date | ||||||
21 | of the rule adopted pursuant to this paragraph, all providers | ||||||
22 | must meet the accreditation requirement. | ||||||
23 | In order to promote environmental responsibility, meet the | ||||||
24 | needs of recipients and enrollees, and achieve significant | ||||||
25 | cost savings, the Department, or a managed care organization | ||||||
26 | under contract with the Department, may provide recipients or |
| |||||||
| |||||||
1 | managed care enrollees who have a prescription or Certificate | ||||||
2 | of Medical Necessity access to refurbished durable medical | ||||||
3 | equipment under this Section (excluding prosthetic and | ||||||
4 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
5 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
6 | products and associated services) through the State's | ||||||
7 | assistive technology program's reutilization program, using | ||||||
8 | staff with the Assistive Technology Professional (ATP) | ||||||
9 | Certification if the refurbished durable medical equipment: | ||||||
10 | (i) is available; (ii) is less expensive, including shipping | ||||||
11 | costs, than new durable medical equipment of the same type; | ||||||
12 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
13 | cleaned, disinfected, sterilized, and safe in accordance with | ||||||
14 | federal Food and Drug Administration regulations and guidance | ||||||
15 | governing the reprocessing of medical devices in health care | ||||||
16 | settings; and (v) equally meets the needs of the recipient or | ||||||
17 | enrollee. The reutilization program shall confirm that the | ||||||
18 | recipient or enrollee is not already in receipt of the same or | ||||||
19 | similar equipment from another service provider, and that the | ||||||
20 | refurbished durable medical equipment equally meets the needs | ||||||
21 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
22 | be construed to limit recipient or enrollee choice to obtain | ||||||
23 | new durable medical equipment or place any additional prior | ||||||
24 | authorization conditions on enrollees of managed care | ||||||
25 | organizations. | ||||||
26 | The Department shall execute, relative to the nursing home |
| |||||||
| |||||||
1 | prescreening project, written inter-agency agreements with the | ||||||
2 | Department of Human Services and the Department on Aging, to | ||||||
3 | effect the following: (i) intake procedures and common | ||||||
4 | eligibility criteria for those persons who are receiving | ||||||
5 | non-institutional services; and (ii) the establishment and | ||||||
6 | development of non-institutional services in areas of the | ||||||
7 | State where they are not currently available or are | ||||||
8 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
9 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
10 | increase in the determination of need (DON) scores from 29 to | ||||||
11 | 37 for applicants for institutional and home and | ||||||
12 | community-based long term care; if and only if federal | ||||||
13 | approval is not granted, the Department may, in conjunction | ||||||
14 | with other affected agencies, implement utilization controls | ||||||
15 | or changes in benefit packages to effectuate a similar savings | ||||||
16 | amount for this population; and (iv) no later than July 1, | ||||||
17 | 2013, minimum level of care eligibility criteria for | ||||||
18 | institutional and home and community-based long term care; and | ||||||
19 | (v) no later than October 1, 2013, establish procedures to | ||||||
20 | permit long term care providers access to eligibility scores | ||||||
21 | for individuals with an admission date who are seeking or | ||||||
22 | receiving services from the long term care provider. In order | ||||||
23 | to select the minimum level of care eligibility criteria, the | ||||||
24 | Governor shall establish a workgroup that includes affected | ||||||
25 | agency representatives and stakeholders representing the | ||||||
26 | institutional and home and community-based long term care |
| |||||||
| |||||||
1 | interests. This Section shall not restrict the Department from | ||||||
2 | implementing lower level of care eligibility criteria for | ||||||
3 | community-based services in circumstances where federal | ||||||
4 | approval has been granted. | ||||||
5 | The Illinois Department shall develop and operate, in | ||||||
6 | cooperation with other State Departments and agencies and in | ||||||
7 | compliance with applicable federal laws and regulations, | ||||||
8 | appropriate and effective systems of health care evaluation | ||||||
9 | and programs for monitoring of utilization of health care | ||||||
10 | services and facilities, as it affects persons eligible for | ||||||
11 | medical assistance under this Code. | ||||||
12 | The Illinois Department shall report annually to the | ||||||
13 | General Assembly, no later than the second Friday in April of | ||||||
14 | 1979 and each year thereafter, in regard to: | ||||||
15 | (a) actual statistics and trends in utilization of | ||||||
16 | medical services by public aid recipients; | ||||||
17 | (b) actual statistics and trends in the provision of | ||||||
18 | the various medical services by medical vendors; | ||||||
19 | (c) current rate structures and proposed changes in | ||||||
20 | those rate structures for the various medical vendors; and | ||||||
21 | (d) efforts at utilization review and control by the | ||||||
22 | Illinois Department. | ||||||
23 | The period covered by each report shall be the 3 years | ||||||
24 | ending on the June 30 prior to the report. The report shall | ||||||
25 | include suggested legislation for consideration by the General | ||||||
26 | Assembly. The requirement for reporting to the General |
| |||||||
| |||||||
1 | Assembly shall be satisfied by filing copies of the report as | ||||||
2 | required by Section 3.1 of the General Assembly Organization | ||||||
3 | Act, and filing such additional copies with the State | ||||||
4 | Government Report Distribution Center for the General Assembly | ||||||
5 | as is required under paragraph (t) of Section 7 of the State | ||||||
6 | Library Act. | ||||||
7 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
8 | any, is conditioned on the rules being adopted in accordance | ||||||
9 | with all provisions of the Illinois Administrative Procedure | ||||||
10 | Act and all rules and procedures of the Joint Committee on | ||||||
11 | Administrative Rules; any purported rule not so adopted, for | ||||||
12 | whatever reason, is unauthorized. | ||||||
13 | On and after July 1, 2012, the Department shall reduce any | ||||||
14 | rate of reimbursement for services or other payments or alter | ||||||
15 | any methodologies authorized by this Code to reduce any rate | ||||||
16 | of reimbursement for services or other payments in accordance | ||||||
17 | with Section 5-5e. | ||||||
18 | Because kidney transplantation can be an appropriate, | ||||||
19 | cost-effective alternative to renal dialysis when medically | ||||||
20 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
21 | of this Code, beginning October 1, 2014, the Department shall | ||||||
22 | cover kidney transplantation for noncitizens with end-stage | ||||||
23 | renal disease who are not eligible for comprehensive medical | ||||||
24 | benefits, who meet the residency requirements of Section 5-3 | ||||||
25 | of this Code, and who would otherwise meet the financial | ||||||
26 | requirements of the appropriate class of eligible persons |
| |||||||
| |||||||
1 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
2 | kidney transplantation, such person must be receiving | ||||||
3 | emergency renal dialysis services covered by the Department. | ||||||
4 | Providers under this Section shall be prior approved and | ||||||
5 | certified by the Department to perform kidney transplantation | ||||||
6 | and the services under this Section shall be limited to | ||||||
7 | services associated with kidney transplantation. | ||||||
8 | Notwithstanding any other provision of this Code to the | ||||||
9 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
10 | medication assisted treatment prescribed for the treatment of | ||||||
11 | alcohol dependence or treatment of opioid dependence shall be | ||||||
12 | covered under both fee-for-service fee for service and managed | ||||||
13 | care medical assistance programs for persons who are otherwise | ||||||
14 | eligible for medical assistance under this Article and shall | ||||||
15 | not be subject to any (1) utilization control, other than | ||||||
16 | those established under the American Society of Addiction | ||||||
17 | Medicine patient placement criteria, (2) prior authorization | ||||||
18 | mandate, or (3) lifetime restriction limit mandate. | ||||||
19 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
20 | for the treatment of an opioid overdose, including the | ||||||
21 | medication product, administration devices, and any pharmacy | ||||||
22 | fees or hospital fees related to the dispensing, distribution, | ||||||
23 | and administration of the opioid antagonist, shall be covered | ||||||
24 | under the medical assistance program for persons who are | ||||||
25 | otherwise eligible for medical assistance under this Article. | ||||||
26 | As used in this Section, "opioid antagonist" means a drug that |
| |||||||
| |||||||
1 | binds to opioid receptors and blocks or inhibits the effect of | ||||||
2 | opioids acting on those receptors, including, but not limited | ||||||
3 | to, naloxone hydrochloride or any other similarly acting drug | ||||||
4 | approved by the U.S. Food and Drug Administration. The | ||||||
5 | Department shall not impose a copayment on the coverage | ||||||
6 | provided for naloxone hydrochloride under the medical | ||||||
7 | assistance program. | ||||||
8 | Upon federal approval, the Department shall provide | ||||||
9 | coverage and reimbursement for all drugs that are approved for | ||||||
10 | marketing by the federal Food and Drug Administration and that | ||||||
11 | are recommended by the federal Public Health Service or the | ||||||
12 | United States Centers for Disease Control and Prevention for | ||||||
13 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
14 | services, including, but not limited to, HIV and sexually | ||||||
15 | transmitted infection screening, treatment for sexually | ||||||
16 | transmitted infections, medical monitoring, assorted labs, and | ||||||
17 | counseling to reduce the likelihood of HIV infection among | ||||||
18 | individuals who are not infected with HIV but who are at high | ||||||
19 | risk of HIV infection. | ||||||
20 | A federally qualified health center, as defined in Section | ||||||
21 | 1905(l)(2)(B) of the federal Social Security Act, shall be | ||||||
22 | reimbursed by the Department in accordance with the federally | ||||||
23 | qualified health center's encounter rate for services provided | ||||||
24 | to medical assistance recipients that are performed by a | ||||||
25 | dental hygienist, as defined under the Illinois Dental | ||||||
26 | Practice Act, working under the general supervision of a |
| |||||||
| |||||||
1 | dentist and employed by a federally qualified health center. | ||||||
2 | Within 90 days after October 8, 2021 (the effective date | ||||||
3 | of Public Act 102-665), the Department shall seek federal | ||||||
4 | approval of a State Plan amendment to expand coverage for | ||||||
5 | family planning services that includes presumptive eligibility | ||||||
6 | to individuals whose income is at or below 208% of the federal | ||||||
7 | poverty level. Coverage under this Section shall be effective | ||||||
8 | beginning no later than December 1, 2022. | ||||||
9 | Subject to approval by the federal Centers for Medicare | ||||||
10 | and Medicaid Services of a Title XIX State Plan amendment | ||||||
11 | electing the Program of All-Inclusive Care for the Elderly | ||||||
12 | (PACE) as a State Medicaid option, as provided for by Subtitle | ||||||
13 | I (commencing with Section 4801) of Title IV of the Balanced | ||||||
14 | Budget Act of 1997 (Public Law 105-33) and Part 460 | ||||||
15 | (commencing with Section 460.2) of Subchapter E of Title 42 of | ||||||
16 | the Code of Federal Regulations, PACE program services shall | ||||||
17 | become a covered benefit of the medical assistance program, | ||||||
18 | subject to criteria established in accordance with all | ||||||
19 | applicable laws. | ||||||
20 | Notwithstanding any other provision of this Code, | ||||||
21 | community-based pediatric palliative care from a trained | ||||||
22 | interdisciplinary team shall be covered under the medical | ||||||
23 | assistance program as provided in Section 15 of the Pediatric | ||||||
24 | Palliative Care Act. | ||||||
25 | Notwithstanding any other provision of this Code, within | ||||||
26 | 12 months after June 2, 2022 (the effective date of Public Act |
| |||||||
| |||||||
1 | 102-1037) and subject to federal approval, acupuncture | ||||||
2 | services performed by an acupuncturist licensed under the | ||||||
3 | Acupuncture Practice Act who is acting within the scope of his | ||||||
4 | or her license shall be covered under the medical assistance | ||||||
5 | program. The Department shall apply for any federal waiver or | ||||||
6 | State Plan amendment, if required, to implement this | ||||||
7 | paragraph. The Department may adopt any rules, including | ||||||
8 | standards and criteria, necessary to implement this paragraph. | ||||||
9 | Notwithstanding any other provision of this Code, the | ||||||
10 | medical assistance program shall, subject to appropriation and | ||||||
11 | federal approval, reimburse hospitals for costs associated | ||||||
12 | with a newborn screening test for the presence of | ||||||
13 | metachromatic leukodystrophy, as required under the Newborn | ||||||
14 | Metabolic Screening Act, at a rate not less than the fee | ||||||
15 | charged by the Department of Public Health. The Department | ||||||
16 | shall seek federal approval before the implementation of the | ||||||
17 | newborn screening test fees by the Department of Public | ||||||
18 | Health. | ||||||
19 | Notwithstanding any other provision of this Code, | ||||||
20 | beginning on January 1, 2024, subject to federal approval, | ||||||
21 | cognitive assessment and care planning services provided to a | ||||||
22 | person who experiences signs or symptoms of cognitive | ||||||
23 | impairment, as defined by the Diagnostic and Statistical | ||||||
24 | Manual of Mental Disorders, Fifth Edition, shall be covered | ||||||
25 | under the medical assistance program for persons who are | ||||||
26 | otherwise eligible for medical assistance under this Article. |
| |||||||
| |||||||
1 | Notwithstanding any other provision of this Code, | ||||||
2 | medically necessary reconstructive services that are intended | ||||||
3 | to restore physical appearance shall be covered under the | ||||||
4 | medical assistance program for persons who are otherwise | ||||||
5 | eligible for medical assistance under this Article. As used in | ||||||
6 | this paragraph, "reconstructive services" means treatments | ||||||
7 | performed on structures of the body damaged by trauma to | ||||||
8 | restore physical appearance. | ||||||
9 | (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; | ||||||
10 | 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article | ||||||
11 | 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, | ||||||
12 | eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; | ||||||
13 | 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. | ||||||
14 | 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; | ||||||
15 | 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. | ||||||
16 | 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; | ||||||
17 | 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. | ||||||
18 | 1-1-24; revised 12-15-23.) | ||||||
19 | ARTICLE 95. | ||||||
20 | Section 95-5. The Specialized Mental Health Rehabilitation | ||||||
21 | Act of 2013 is amended by changing Section 5-107 as follows: | ||||||
22 | (210 ILCS 49/5-107) | ||||||
23 | Sec. 5-107. Quality of life enhancement. Beginning on July |
| |||||||
| |||||||
1 | 1, 2019, for improving the quality of life and the quality of | ||||||
2 | care, an additional payment shall be awarded to a facility for | ||||||
3 | their single occupancy rooms. This payment shall be in | ||||||
4 | addition to the rate for recovery and rehabilitation. The | ||||||
5 | additional rate for single room occupancy shall be no less | ||||||
6 | than $10 per day, per single room occupancy. The Department of | ||||||
7 | Healthcare and Family Services shall adjust payment to | ||||||
8 | Medicaid managed care entities to cover these costs. Beginning | ||||||
9 | July 1, 2022, for improving the quality of life and the quality | ||||||
10 | of care, a payment of no less than $5 per day, per single room | ||||||
11 | occupancy shall be added to the existing $10 additional per | ||||||
12 | day, per single room occupancy rate for a total of at least $15 | ||||||
13 | per day, per single room occupancy. For improving the quality | ||||||
14 | of life and the quality of care, on January 1, 2024, a payment | ||||||
15 | of no less than $10.50 per day, per single room occupancy shall | ||||||
16 | be added to the existing $15 additional per day, per single | ||||||
17 | room occupancy rate for a total of at least $25.50 per day, per | ||||||
18 | single room occupancy. For improving the quality of life and | ||||||
19 | the quality of care, beginning on January 1, 2025, a payment of | ||||||
20 | no less than $10 per day, per single room occupancy shall be | ||||||
21 | added to the existing $25.50 additional per day, per single | ||||||
22 | room occupancy rate for a total of at least $35.50 per day, per | ||||||
23 | single room occupancy. Beginning July 1, 2022, for improving | ||||||
24 | the quality of life and the quality of care, an additional | ||||||
25 | payment shall be awarded to a facility for its dual-occupancy | ||||||
26 | rooms. This payment shall be in addition to the rate for |
| |||||||
| |||||||
1 | recovery and rehabilitation. The additional rate for | ||||||
2 | dual-occupancy rooms shall be no less than $10 per day, per | ||||||
3 | Medicaid-occupied bed, in each dual-occupancy room. Beginning | ||||||
4 | January 1, 2024, for improving the quality of life and the | ||||||
5 | quality of care, a payment of no less than $4.50 per day, per | ||||||
6 | dual-occupancy room shall be added to the existing $10 | ||||||
7 | additional per day, per dual-occupancy room rate for a total | ||||||
8 | of at least $14.50, per Medicaid-occupied bed, in each | ||||||
9 | dual-occupancy room. The Department of Healthcare and Family | ||||||
10 | Services shall adjust payment to Medicaid managed care | ||||||
11 | entities to cover these costs. As used in this Section, | ||||||
12 | "dual-occupancy room" means a room that contains 2 resident | ||||||
13 | beds. | ||||||
14 | (Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24 .) | ||||||
15 | ARTICLE 100. | ||||||
16 | Section 100-5. The Illinois Public Aid Code is amended by | ||||||
17 | changing Section 5-5.01a as follows: | ||||||
18 | (305 ILCS 5/5-5.01a) | ||||||
19 | Sec. 5-5.01a. Supportive living facilities program. | ||||||
20 | (a) The Department shall establish and provide oversight | ||||||
21 | for a program of supportive living facilities that seek to | ||||||
22 | promote resident independence, dignity, respect, and | ||||||
23 | well-being in the most cost-effective manner. |
| |||||||
| |||||||
1 | A supportive living facility is (i) a free-standing | ||||||
2 | facility or (ii) a distinct physical and operational entity | ||||||
3 | within a mixed-use building that meets the criteria | ||||||
4 | established in subsection (d). A supportive living facility | ||||||
5 | integrates housing with health, personal care, and supportive | ||||||
6 | services and is a designated setting that offers residents | ||||||
7 | their own separate, private, and distinct living units. | ||||||
8 | Sites for the operation of the program shall be selected | ||||||
9 | by the Department based upon criteria that may include the | ||||||
10 | need for services in a geographic area, the availability of | ||||||
11 | funding, and the site's ability to meet the standards. | ||||||
12 | (b) Beginning July 1, 2014, subject to federal approval, | ||||||
13 | the Medicaid rates for supportive living facilities shall be | ||||||
14 | equal to the supportive living facility Medicaid rate | ||||||
15 | effective on June 30, 2014 increased by 8.85%. Once the | ||||||
16 | assessment imposed at Article V-G of this Code is determined | ||||||
17 | to be a permissible tax under Title XIX of the Social Security | ||||||
18 | Act, the Department shall increase the Medicaid rates for | ||||||
19 | supportive living facilities effective on July 1, 2014 by | ||||||
20 | 9.09%. The Department shall apply this increase retroactively | ||||||
21 | to coincide with the imposition of the assessment in Article | ||||||
22 | V-G of this Code in accordance with the approval for federal | ||||||
23 | financial participation by the Centers for Medicare and | ||||||
24 | Medicaid Services. | ||||||
25 | The Medicaid rates for supportive living facilities | ||||||
26 | effective on July 1, 2017 must be equal to the rates in effect |
| |||||||
| |||||||
1 | for supportive living facilities on June 30, 2017 increased by | ||||||
2 | 2.8%. | ||||||
3 | The Medicaid rates for supportive living facilities | ||||||
4 | effective on July 1, 2018 must be equal to the rates in effect | ||||||
5 | for supportive living facilities on June 30, 2018. | ||||||
6 | Subject to federal approval, the Medicaid rates for | ||||||
7 | supportive living services on and after July 1, 2019 must be at | ||||||
8 | least 54.3% of the average total nursing facility services per | ||||||
9 | diem for the geographic areas defined by the Department while | ||||||
10 | maintaining the rate differential for dementia care and must | ||||||
11 | be updated whenever the total nursing facility service per | ||||||
12 | diems are updated. Beginning July 1, 2022, upon the | ||||||
13 | implementation of the Patient Driven Payment Model, Medicaid | ||||||
14 | rates for supportive living services must be at least 54.3% of | ||||||
15 | the average total nursing services per diem rate for the | ||||||
16 | geographic areas. For purposes of this provision, the average | ||||||
17 | total nursing services per diem rate shall include all add-ons | ||||||
18 | for nursing facilities for the geographic area provided for in | ||||||
19 | Section 5-5.2. The rate differential for dementia care must be | ||||||
20 | maintained in these rates and the rates shall be updated | ||||||
21 | whenever nursing facility per diem rates are updated. | ||||||
22 | Subject to federal approval, beginning January 1, 2024, | ||||||
23 | the dementia care rate for supportive living services must be | ||||||
24 | no less than the non-dementia care supportive living services | ||||||
25 | rate multiplied by 1.5. | ||||||
26 | (c) The Department may adopt rules to implement this |
| |||||||
| |||||||
1 | Section. Rules that establish or modify the services, | ||||||
2 | standards, and conditions for participation in the program | ||||||
3 | shall be adopted by the Department in consultation with the | ||||||
4 | Department on Aging, the Department of Rehabilitation | ||||||
5 | Services, and the Department of Mental Health and | ||||||
6 | Developmental Disabilities (or their successor agencies). | ||||||
7 | (d) Subject to federal approval by the Centers for | ||||||
8 | Medicare and Medicaid Services, the Department shall accept | ||||||
9 | for consideration of certification under the program any | ||||||
10 | application for a site or building where distinct parts of the | ||||||
11 | site or building are designated for purposes other than the | ||||||
12 | provision of supportive living services, but only if: | ||||||
13 | (1) those distinct parts of the site or building are | ||||||
14 | not designated for the purpose of providing assisted | ||||||
15 | living services as required under the Assisted Living and | ||||||
16 | Shared Housing Act; | ||||||
17 | (2) those distinct parts of the site or building are | ||||||
18 | completely separate from the part of the building used for | ||||||
19 | the provision of supportive living program services, | ||||||
20 | including separate entrances; | ||||||
21 | (3) those distinct parts of the site or building do | ||||||
22 | not share any common spaces with the part of the building | ||||||
23 | used for the provision of supportive living program | ||||||
24 | services; and | ||||||
25 | (4) those distinct parts of the site or building do | ||||||
26 | not share staffing with the part of the building used for |
| |||||||
| |||||||
1 | the provision of supportive living program services. | ||||||
2 | (e) Facilities or distinct parts of facilities which are | ||||||
3 | selected as supportive living facilities and are in good | ||||||
4 | standing with the Department's rules are exempt from the | ||||||
5 | provisions of the Nursing Home Care Act and the Illinois | ||||||
6 | Health Facilities Planning Act. | ||||||
7 | (f) Section 9817 of the American Rescue Plan Act of 2021 | ||||||
8 | (Public Law 117-2) authorizes a 10% enhanced federal medical | ||||||
9 | assistance percentage for supportive living services for a | ||||||
10 | 12-month period from April 1, 2021 through March 31, 2022. | ||||||
11 | Subject to federal approval, including the approval of any | ||||||
12 | necessary waiver amendments or other federally required | ||||||
13 | documents or assurances, for a 12-month period the Department | ||||||
14 | must pay a supplemental $26 per diem rate to all supportive | ||||||
15 | living facilities with the additional federal financial | ||||||
16 | participation funds that result from the enhanced federal | ||||||
17 | medical assistance percentage from April 1, 2021 through March | ||||||
18 | 31, 2022. The Department may issue parameters around how the | ||||||
19 | supplemental payment should be spent, including quality | ||||||
20 | improvement activities. The Department may alter the form, | ||||||
21 | methods, or timeframes concerning the supplemental per diem | ||||||
22 | rate to comply with any subsequent changes to federal law, | ||||||
23 | changes made by guidance issued by the federal Centers for | ||||||
24 | Medicare and Medicaid Services, or other changes necessary to | ||||||
25 | receive the enhanced federal medical assistance percentage. | ||||||
26 | (g) All applications for the expansion of supportive |
| |||||||
| |||||||
1 | living dementia care settings involving sites not approved by | ||||||
2 | the Department by January 1, 2024 on the effective date of this | ||||||
3 | amendatory Act of the 103rd General Assembly may allow new | ||||||
4 | elderly non-dementia units in addition to new dementia care | ||||||
5 | units. The Department may approve such applications only if | ||||||
6 | the application has: (1) no more than one non-dementia care | ||||||
7 | unit for each dementia care unit and (2) the site is not | ||||||
8 | located within 4 miles of an existing supportive living | ||||||
9 | program site in Cook County (including the City of Chicago), | ||||||
10 | not located within 12 miles of an existing supportive living | ||||||
11 | program site in Alexander, Bond, Boone, Calhoun, Champaign, | ||||||
12 | Clinton, DeKalb, DuPage Fulton, Grundy, Henry, Jackson, | ||||||
13 | Jersey, Johnson, Kane, Kankakee, Kendall, Lake, Macon, | ||||||
14 | Macoupin, Madison, Marshall, McHenry, McLean, Menard, Mercer, | ||||||
15 | Monroe, Peoria, Piatt, Rock Island, Sangamon, Stark, St. | ||||||
16 | Clair, Tazewell, Vermilion, Will, Williamson, Winnebago, or | ||||||
17 | Woodford counties County, Kane County, Lake County, McHenry | ||||||
18 | County, or Will County , or not located within 25 miles of an | ||||||
19 | existing supportive living program site in any other county. | ||||||
20 | (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; | ||||||
21 | 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, | ||||||
22 | Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.) | ||||||
23 | ARTICLE 105. | ||||||
24 | Section 105-5. The Illinois Public Aid Code is amended by |
| |||||||
| |||||||
1 | changing Section 5-36 as follows: | ||||||
2 | (305 ILCS 5/5-36) | ||||||
3 | Sec. 5-36. Pharmacy benefits. | ||||||
4 | (a)(1) The Department may enter into a contract with a | ||||||
5 | third party on a fee-for-service reimbursement model for the | ||||||
6 | purpose of administering pharmacy benefits as provided in this | ||||||
7 | Section for members not enrolled in a Medicaid managed care | ||||||
8 | organization; however, these services shall be approved by the | ||||||
9 | Department. The Department shall ensure coordination of care | ||||||
10 | between the third-party administrator and managed care | ||||||
11 | organizations as a consideration in any contracts established | ||||||
12 | in accordance with this Section. Any managed care techniques, | ||||||
13 | principles, or administration of benefits utilized in | ||||||
14 | accordance with this subsection shall comply with State law. | ||||||
15 | (2) The following shall apply to contracts between | ||||||
16 | entities contracting relating to the Department's third-party | ||||||
17 | administrators and pharmacies: | ||||||
18 | (A) the Department shall approve any contract between | ||||||
19 | a third-party administrator and a pharmacy; | ||||||
20 | (B) the Department's third-party administrator shall | ||||||
21 | not change the terms of a contract between a third-party | ||||||
22 | administrator and a pharmacy without written approval by | ||||||
23 | the Department; and | ||||||
24 | (C) the Department's third-party administrator shall | ||||||
25 | not create, modify, implement, or indirectly establish any |
| |||||||
| |||||||
1 | fee on a pharmacy, pharmacist, or a recipient of medical | ||||||
2 | assistance without written approval by the Department. | ||||||
3 | (b) The provisions of this Section shall not apply to | ||||||
4 | outpatient pharmacy services provided by a health care | ||||||
5 | facility registered as a covered entity pursuant to 42 U.S.C. | ||||||
6 | 256b or any pharmacy owned by or contracted with the covered | ||||||
7 | entity. A Medicaid managed care organization shall, either | ||||||
8 | directly or through a pharmacy benefit manager, administer and | ||||||
9 | reimburse outpatient pharmacy claims submitted by a health | ||||||
10 | care facility registered as a covered entity pursuant to 42 | ||||||
11 | U.S.C. 256b, its owned pharmacies, and contracted pharmacies | ||||||
12 | in accordance with the contractual agreements the Medicaid | ||||||
13 | managed care organization or its pharmacy benefit manager has | ||||||
14 | with such facilities and pharmacies and in accordance with | ||||||
15 | subsection (h-5). | ||||||
16 | (b-5) Any pharmacy benefit manager that contracts with a | ||||||
17 | Medicaid managed care organization to administer and reimburse | ||||||
18 | pharmacy claims as provided in this Section must be registered | ||||||
19 | with the Director of Insurance in accordance with Section | ||||||
20 | 513b2 of the Illinois Insurance Code. | ||||||
21 | (c) On at least an annual basis, the Director of the | ||||||
22 | Department of Healthcare and Family Services shall submit a | ||||||
23 | report beginning no later than one year after January 1, 2020 | ||||||
24 | (the effective date of Public Act 101-452) that provides an | ||||||
25 | update on any contract, contract issues, formulary, dispensing | ||||||
26 | fees, and maximum allowable cost concerns regarding a |
| |||||||
| |||||||
1 | third-party administrator and managed care. The requirement | ||||||
2 | for reporting to the General Assembly shall be satisfied by | ||||||
3 | filing copies of the report with the Speaker, the Minority | ||||||
4 | Leader, and the Clerk of the House of Representatives and with | ||||||
5 | the President, the Minority Leader, and the Secretary of the | ||||||
6 | Senate. The Department shall take care that no proprietary | ||||||
7 | information is included in the report required under this | ||||||
8 | Section. | ||||||
9 | (d) A pharmacy benefit manager shall notify the Department | ||||||
10 | in writing of any activity, policy, or practice of the | ||||||
11 | pharmacy benefit manager that directly or indirectly presents | ||||||
12 | a conflict of interest that interferes with the discharge of | ||||||
13 | the pharmacy benefit manager's duty to a managed care | ||||||
14 | organization to exercise its contractual duties. "Conflict of | ||||||
15 | interest" shall be defined by rule by the Department. | ||||||
16 | (e) A pharmacy benefit manager shall, upon request, | ||||||
17 | disclose to the Department the following information: | ||||||
18 | (1) whether the pharmacy benefit manager has a | ||||||
19 | contract, agreement, or other arrangement with a | ||||||
20 | pharmaceutical manufacturer to exclusively dispense or | ||||||
21 | provide a drug to a managed care organization's enrollees, | ||||||
22 | and the aggregate amounts of consideration of economic | ||||||
23 | benefits collected or received pursuant to that | ||||||
24 | arrangement; | ||||||
25 | (2) the percentage of claims payments made by the | ||||||
26 | pharmacy benefit manager to pharmacies owned, managed, or |
| |||||||
| |||||||
1 | controlled by the pharmacy benefit manager or any of the | ||||||
2 | pharmacy benefit manager's management companies, parent | ||||||
3 | companies, subsidiary companies, or jointly held | ||||||
4 | companies; | ||||||
5 | (3) the aggregate amount of the fees or assessments | ||||||
6 | imposed on, or collected from, pharmacy providers; and | ||||||
7 | (4) the average annualized percentage of revenue | ||||||
8 | collected by the pharmacy benefit manager as a result of | ||||||
9 | each contract it has executed with a managed care | ||||||
10 | organization contracted by the Department to provide | ||||||
11 | medical assistance benefits which is not paid by the | ||||||
12 | pharmacy benefit manager to pharmacy providers and | ||||||
13 | pharmaceutical manufacturers or labelers or in order to | ||||||
14 | perform administrative functions pursuant to its contracts | ||||||
15 | with managed care organizations ; . | ||||||
16 | (5) the total number of prescriptions dispensed under | ||||||
17 | each contract the pharmacy benefit manager has with a | ||||||
18 | managed care organization (MCO) contracted by the | ||||||
19 | Department to provide medical assistance benefits; | ||||||
20 | (6) the aggregate wholesale acquisition cost for drugs | ||||||
21 | that were dispensed to enrollees in each MCO with which | ||||||
22 | the pharmacy benefit manager has a contract by any | ||||||
23 | pharmacy owned, managed, or controlled by the pharmacy | ||||||
24 | benefit manager or any of the pharmacy benefit manager's | ||||||
25 | management companies, parent companies, subsidiary | ||||||
26 | companies, or jointly-held companies; |
| |||||||
| |||||||
1 | (7) the aggregate amount of administrative fees that | ||||||
2 | the pharmacy benefit manager received from all | ||||||
3 | pharmaceutical manufacturers for prescriptions dispensed | ||||||
4 | to MCO enrollees; | ||||||
5 | (8) for each MCO with which the pharmacy benefit | ||||||
6 | manager has a contract, the aggregate amount of payments | ||||||
7 | received by the pharmacy benefit manager from the MCO; | ||||||
8 | (9) for each MCO with which the pharmacy benefit | ||||||
9 | manager has a contract, the aggregate amount of | ||||||
10 | reimbursements the pharmacy benefit manager paid to | ||||||
11 | contracting pharmacies; and | ||||||
12 | (10) any other information considered necessary by the | ||||||
13 | Department. | ||||||
14 | (f) The information disclosed under subsection (e) shall | ||||||
15 | include all retail, mail order, specialty, and compounded | ||||||
16 | prescription products. All information made available to the | ||||||
17 | Department under subsection (e) is confidential and not | ||||||
18 | subject to disclosure under the Freedom of Information Act. | ||||||
19 | All information made available to the Department under | ||||||
20 | subsection (e) shall not be reported or distributed in any way | ||||||
21 | that compromises its competitive, proprietary, or financial | ||||||
22 | value. The information shall only be used by the Department to | ||||||
23 | assess the contract, agreement, or other arrangements made | ||||||
24 | between a pharmacy benefit manager and a pharmacy provider, | ||||||
25 | pharmaceutical manufacturer or labeler, managed care | ||||||
26 | organization, or other entity, as applicable. |
| |||||||
| |||||||
1 | (g) A pharmacy benefit manager shall disclose directly in | ||||||
2 | writing to a pharmacy provider or pharmacy services | ||||||
3 | administrative organization contracting with the pharmacy | ||||||
4 | benefit manager of any material change to a contract provision | ||||||
5 | that affects the terms of the reimbursement, the process for | ||||||
6 | verifying benefits and eligibility, dispute resolution, | ||||||
7 | procedures for verifying drugs included on the formulary, and | ||||||
8 | contract termination at least 30 days prior to the date of the | ||||||
9 | change to the provision. The terms of this subsection shall be | ||||||
10 | deemed met if the pharmacy benefit manager posts the | ||||||
11 | information on a website, viewable by the public. A pharmacy | ||||||
12 | service administration organization shall notify all contract | ||||||
13 | pharmacies of any material change, as described in this | ||||||
14 | subsection, within 2 days of notification. As used in this | ||||||
15 | Section, "pharmacy services administrative organization" means | ||||||
16 | an entity operating within the State that contracts with | ||||||
17 | independent pharmacies to conduct business on their behalf | ||||||
18 | with third-party payers. A pharmacy services administrative | ||||||
19 | organization may provide administrative services to pharmacies | ||||||
20 | and negotiate and enter into contracts with third-party payers | ||||||
21 | or pharmacy benefit managers on behalf of pharmacies. | ||||||
22 | (h) A pharmacy benefit manager shall not include the | ||||||
23 | following in a contract with a pharmacy provider: | ||||||
24 | (1) a provision prohibiting the provider from | ||||||
25 | informing a patient of a less costly alternative to a | ||||||
26 | prescribed medication; or |
| |||||||
| |||||||
1 | (2) a provision that prohibits the provider from | ||||||
2 | dispensing a particular amount of a prescribed medication, | ||||||
3 | if the pharmacy benefit manager allows that amount to be | ||||||
4 | dispensed through a pharmacy owned or controlled by the | ||||||
5 | pharmacy benefit manager, unless the prescription drug is | ||||||
6 | subject to restricted distribution by the United States | ||||||
7 | Food and Drug Administration or requires special handling, | ||||||
8 | provider coordination, or patient education that cannot be | ||||||
9 | provided by a retail pharmacy. | ||||||
10 | (h-5) Unless required by law, a Medicaid managed care | ||||||
11 | organization or pharmacy benefit manager administering or | ||||||
12 | managing benefits on behalf of a Medicaid managed care | ||||||
13 | organization shall not refuse to contract with a 340B entity | ||||||
14 | or 340B pharmacy for refusing to accept less favorable payment | ||||||
15 | terms or reimbursement methodologies when compared to | ||||||
16 | similarly situated non-340B entities and shall not include in | ||||||
17 | a contract with a 340B entity or 340B pharmacy a provision | ||||||
18 | that: | ||||||
19 | (1) imposes any fee, chargeback, or rate adjustment | ||||||
20 | that is not similarly imposed on similarly situated | ||||||
21 | pharmacies that are not 340B entities or 340B pharmacies; | ||||||
22 | (2) imposes any fee, chargeback, or rate adjustment | ||||||
23 | that exceeds the fee, chargeback, or rate adjustment that | ||||||
24 | is not similarly imposed on similarly situated pharmacies | ||||||
25 | that are not 340B entities or 340B pharmacies; | ||||||
26 | (3) prevents or interferes with an individual's choice |
| |||||||
| |||||||
1 | to receive a prescription drug from a 340B entity or 340B | ||||||
2 | pharmacy through any legally permissible means; | ||||||
3 | (4) excludes a 340B entity or 340B pharmacy from a | ||||||
4 | pharmacy network on the basis of whether the 340B entity | ||||||
5 | or 340B pharmacy participates in the 340B drug discount | ||||||
6 | program; | ||||||
7 | (5) prevents a 340B entity or 340B pharmacy from using | ||||||
8 | a drug purchased under the 340B drug discount program so | ||||||
9 | long as the drug recipient is a patient of the 340B entity; | ||||||
10 | nothing in this Section exempts a 340B pharmacy from | ||||||
11 | following the Department's preferred drug list or from any | ||||||
12 | prior approval requirements of the Department or the | ||||||
13 | Medicaid managed care organization that are imposed on the | ||||||
14 | drug for all pharmacies; or | ||||||
15 | (6) any other provision that discriminates against a | ||||||
16 | 340B entity or 340B pharmacy by treating a 340B entity or | ||||||
17 | 340B pharmacy differently than non-340B entities or | ||||||
18 | non-340B pharmacies for any reason relating to the | ||||||
19 | entity's participation in the 340B drug discount program. | ||||||
20 | A provision that violates this subsection in any contract | ||||||
21 | between a Medicaid managed care organization or its pharmacy | ||||||
22 | benefit manager and a 340B entity entered into, amended, or | ||||||
23 | renewed after July 1, 2022 shall be void and unenforceable. | ||||||
24 | In this subsection (h-5): | ||||||
25 | "340B entity" means a covered entity as defined in 42 | ||||||
26 | U.S.C. 256b(a)(4) authorized to participate in the 340B drug |
| |||||||
| |||||||
1 | discount program. | ||||||
2 | "340B pharmacy" means any pharmacy used to dispense 340B | ||||||
3 | drugs for a covered entity, whether entity-owned or external. | ||||||
4 | (i) Nothing in this Section shall be construed to prohibit | ||||||
5 | a pharmacy benefit manager from requiring the same | ||||||
6 | reimbursement and terms and conditions for a pharmacy provider | ||||||
7 | as for a pharmacy owned, controlled, or otherwise associated | ||||||
8 | with the pharmacy benefit manager. | ||||||
9 | (j) A pharmacy benefit manager shall establish and | ||||||
10 | implement a process for the resolution of disputes arising out | ||||||
11 | of this Section, which shall be approved by the Department. | ||||||
12 | (k) The Department shall adopt rules establishing | ||||||
13 | reasonable dispensing fees for fee-for-service payments in | ||||||
14 | accordance with guidance or guidelines from the federal | ||||||
15 | Centers for Medicare and Medicaid Services. | ||||||
16 | (Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; | ||||||
17 | 102-778, eff. 7-1-22.) | ||||||
18 | ARTICLE 110. | ||||||
19 | Section 110-5. The Specialized Mental Health | ||||||
20 | Rehabilitation Act of 2013 is amended by adding Section 5-113 | ||||||
21 | as follows: | ||||||
22 | (210 ILCS 49/5-113 new) | ||||||
23 | Sec. 5-113. Specialized mental health rehabilitation |
| |||||||
| |||||||
1 | facility; one payment. Notwithstanding any other provision of | ||||||
2 | this Act to the contrary, beginning January 1, 2025, there | ||||||
3 | shall be a separate per diem add-on paid solely and | ||||||
4 | exclusively to facilities licensed under this Act that are | ||||||
5 | licensed for only single occupancy rooms and have reduced | ||||||
6 | their licensed capacity. No facility licensed under this Act | ||||||
7 | shall be eligible for these payments if the facility contains | ||||||
8 | any rooms that house more than a single occupant and have | ||||||
9 | failed to reduce the facilities' licensed capacity. | ||||||
10 | The payment shall be a per diem add-on payment. For | ||||||
11 | facilities with less than 100 licensed beds, the add-on | ||||||
12 | payment shall result in a rate not less than $240 per day. For | ||||||
13 | facilities with 100 licensed beds to 130 licensed beds, the | ||||||
14 | add-on payment shall result in a rate not less than $230 per | ||||||
15 | day. For facilities with more than 130 licensed beds, the | ||||||
16 | add-on payment shall result in a rate of not less than $220 per | ||||||
17 | day. All add-on rates shall be based upon the new licensed | ||||||
18 | capacity. | ||||||
19 | Any additional payments in effect after January 1, 2025 | ||||||
20 | under Section 5-107 shall be paid in addition to the amounts | ||||||
21 | listed in this Section. Facilities receiving payments under | ||||||
22 | this Section shall receive payment as prescribed under Section | ||||||
23 | 5-101. | ||||||
24 | ARTICLE 115. |
| |||||||
| |||||||
1 | Section 115-5. The Illinois Public Aid Code is amended by | ||||||
2 | adding Section 5-53 as follows: | ||||||
3 | (305 ILCS 5/5-53 new) | ||||||
4 | Sec. 5-53. Coverage for self-measure blood pressure | ||||||
5 | monitoring services. Subject to federal approval and | ||||||
6 | notwithstanding any other provision of this Code, for services | ||||||
7 | on and after January 1, 2025, the following self-measure blood | ||||||
8 | pressure monitoring services shall be covered and reimbursed | ||||||
9 | under the medical assistance program for persons who are | ||||||
10 | otherwise eligible for medical assistance under this Article: | ||||||
11 | (1) patient education and training services on the | ||||||
12 | set-up and use of a self-measure blood pressure | ||||||
13 | measurement device validated for clinical accuracy and | ||||||
14 | device calibration; and | ||||||
15 | (2) separate self-measurement readings and the | ||||||
16 | collection of data reports by the patient or caregiver to | ||||||
17 | the health care provider in order to communicate blood | ||||||
18 | pressure readings and create or modify treatment plans. | ||||||
19 | ARTICLE 120. | ||||||
20 | (305 ILCS 5/15-6 rep.) | ||||||
21 | Section 120-5. The Illinois Public Aid Code is amended by | ||||||
22 | repealing Section 15-6. |
| |||||||
| |||||||
1 | Article 125. | ||||||
2 | Section 125-5. The State Finance Act is amended by | ||||||
3 | changing Section 5.797 as follows: | ||||||
4 | (30 ILCS 105/5.797) | ||||||
5 | Sec. 5.797. The Electronic Health Record Incentive Fund. | ||||||
6 | This Section is repealed on January 1, 2025. | ||||||
7 | (Source: P.A. 97-169, eff. 7-22-11; 97-813, eff. 7-13-12.) | ||||||
8 | Section 125-10. The Illinois Public Aid Code is amended by | ||||||
9 | changing Section 12-10.6a as follows: | ||||||
10 | (305 ILCS 5/12-10.6a) | ||||||
11 | Sec. 12-10.6a. The Electronic Health Record Incentive | ||||||
12 | Fund. | ||||||
13 | (a) The Electronic Health Record Incentive Fund is a | ||||||
14 | special fund created in the State treasury. All federal moneys | ||||||
15 | received by the Department of Healthcare and Family Services | ||||||
16 | for payments to qualifying health care providers to encourage | ||||||
17 | the adoption and use of certified electronic health records | ||||||
18 | technology pursuant to paragraph 1903(t)(1) of the Social | ||||||
19 | Security Act, shall be deposited into the Fund. | ||||||
20 | (b) Disbursements from the Fund shall be made at the | ||||||
21 | direction of the Director of Healthcare and Family Services to | ||||||
22 | qualifying health care providers, in amounts established under |
| |||||||
| |||||||
1 | applicable federal regulation (42 CFR 495 et seq.), in order | ||||||
2 | to encourage the adoption and use of certified electronic | ||||||
3 | health records technology. | ||||||
4 | (c) On January 1, 2025, or as soon thereafter as | ||||||
5 | practical, the State Comptroller shall direct and the State | ||||||
6 | Treasurer shall transfer the remaining balance from the | ||||||
7 | Electronic Health Record Incentive Fund into the Public Aid | ||||||
8 | Recoveries Trust Fund. Upon completion of the transfer, the | ||||||
9 | Electronic Health Record Incentive Fund is dissolved, and any | ||||||
10 | future deposits due to that Fund and any outstanding | ||||||
11 | obligations or liabilities of that Fund shall pass to the | ||||||
12 | Public Aid Recoveries Trust Fund. | ||||||
13 | (Source: P.A. 97-169, eff. 7-22-11.) | ||||||
14 | Article 130. | ||||||
15 | (30 ILCS 105/5.836 rep.) | ||||||
16 | Section 130-5. The State Finance Act is amended by | ||||||
17 | repealing Section 5.836. | ||||||
18 | (305 ILCS 5/5-31 rep.) | ||||||
19 | (305 ILCS 5/5-32 rep.) | ||||||
20 | Section 130-10. The Illinois Public Aid Code is amended by | ||||||
21 | repealing Sections 5-31 and 5-32. | ||||||
22 | Article 135. |
| |||||||
| |||||||
1 | Section 135-5. The State Finance Act is amended by | ||||||
2 | changing Section 5.481 as follows: | ||||||
3 | (30 ILCS 105/5.481) | ||||||
4 | Sec. 5.481. The Juvenile Rehabilitation Services Medicaid | ||||||
5 | Matching Fund. This Section is repealed on January 1, 2026. | ||||||
6 | (Source: P.A. 90-587, eff. 7-1-98.) | ||||||
7 | Section 135-10. The Illinois Public Aid Code is amended by | ||||||
8 | changing Sections 12-9 and 12-10.4 as follows: | ||||||
9 | (305 ILCS 5/12-9) (from Ch. 23, par. 12-9) | ||||||
10 | Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The | ||||||
11 | Public Aid Recoveries Trust Fund shall consist of (1) | ||||||
12 | recoveries by the Department of Healthcare and Family Services | ||||||
13 | (formerly Illinois Department of Public Aid) authorized by | ||||||
14 | this Code in respect to applicants or recipients under | ||||||
15 | Articles III, IV, V, and VI, including recoveries made by the | ||||||
16 | Department of Healthcare and Family Services (formerly | ||||||
17 | Illinois Department of Public Aid) from the estates of | ||||||
18 | deceased recipients, (2) recoveries made by the Department of | ||||||
19 | Healthcare and Family Services (formerly Illinois Department | ||||||
20 | of Public Aid) in respect to applicants and recipients under | ||||||
21 | the Children's Health Insurance Program Act, and the Covering | ||||||
22 | ALL KIDS Health Insurance Act, (2.5) recoveries made by the |
| |||||||
| |||||||
1 | Department of Healthcare and Family Services in connection | ||||||
2 | with the imposition of an administrative penalty as provided | ||||||
3 | under Section 12-4.45, (3) federal funds received on behalf of | ||||||
4 | and earned by State universities , other State agencies or | ||||||
5 | departments, and local governmental entities for services | ||||||
6 | provided to applicants or recipients covered under this Code, | ||||||
7 | the Children's Health Insurance Program Act, and the Covering | ||||||
8 | ALL KIDS Health Insurance Act, (3.5) federal financial | ||||||
9 | participation revenue related to eligible disbursements made | ||||||
10 | by the Department of Healthcare and Family Services from | ||||||
11 | appropriations required by this Section, and (4) all other | ||||||
12 | moneys received to the Fund, including interest thereon. The | ||||||
13 | Fund shall be held as a special fund in the State Treasury. | ||||||
14 | Disbursements from this Fund shall be only (1) for the | ||||||
15 | reimbursement of claims collected by the Department of | ||||||
16 | Healthcare and Family Services (formerly Illinois Department | ||||||
17 | of Public Aid) through error or mistake, (2) for payment to | ||||||
18 | persons or agencies designated as payees or co-payees on any | ||||||
19 | instrument, whether or not negotiable, delivered to the | ||||||
20 | Department of Healthcare and Family Services (formerly | ||||||
21 | Illinois Department of Public Aid) as a recovery under this | ||||||
22 | Section, such payment to be in proportion to the respective | ||||||
23 | interests of the payees in the amount so collected, (3) for | ||||||
24 | payments to the Department of Human Services for collections | ||||||
25 | made by the Department of Healthcare and Family Services | ||||||
26 | (formerly Illinois Department of Public Aid) on behalf of the |
| |||||||
| |||||||
1 | Department of Human Services under this Code, the Children's | ||||||
2 | Health Insurance Program Act, and the Covering ALL KIDS Health | ||||||
3 | Insurance Act, (4) for payment of administrative expenses | ||||||
4 | incurred in performing the activities authorized under this | ||||||
5 | Code, the Children's Health Insurance Program Act, and the | ||||||
6 | Covering ALL KIDS Health Insurance Act, (5) for payment of | ||||||
7 | fees to persons or agencies in the performance of activities | ||||||
8 | pursuant to the collection of monies owed the State that are | ||||||
9 | collected under this Code, the Children's Health Insurance | ||||||
10 | Program Act, and the Covering ALL KIDS Health Insurance Act, | ||||||
11 | (6) for payments of any amounts which are reimbursable to the | ||||||
12 | federal government which are required to be paid by State | ||||||
13 | warrant by either the State or federal government, and (7) for | ||||||
14 | payments to State universities , other State agencies or | ||||||
15 | departments, and local governmental entities of federal funds | ||||||
16 | for services provided to applicants or recipients covered | ||||||
17 | under this Code, the Children's Health Insurance Program Act, | ||||||
18 | and the Covering ALL KIDS Health Insurance Act. Disbursements | ||||||
19 | from this Fund for purposes of items (4) and (5) of this | ||||||
20 | paragraph shall be subject to appropriations from the Fund to | ||||||
21 | the Department of Healthcare and Family Services (formerly | ||||||
22 | Illinois Department of Public Aid). | ||||||
23 | The balance in this Fund after payment therefrom of any | ||||||
24 | amounts reimbursable to the federal government, and minus the | ||||||
25 | amount reasonably anticipated to be needed to make the | ||||||
26 | disbursements authorized by this Section during the current |
| |||||||
| |||||||
1 | and following 3 calendar months , shall be certified by the | ||||||
2 | Director of Healthcare and Family Services and transferred by | ||||||
3 | the State Comptroller to the Drug Rebate Fund or the | ||||||
4 | Healthcare Provider Relief Fund in the State Treasury, as | ||||||
5 | appropriate, on at least an annual basis by June 30th of each | ||||||
6 | fiscal year. The Director of Healthcare and Family Services | ||||||
7 | may certify and the State Comptroller shall transfer to the | ||||||
8 | Drug Rebate Fund or the Healthcare Provider Relief Fund | ||||||
9 | amounts on a more frequent basis. | ||||||
10 | On July 1, 1999, the State Comptroller shall transfer the | ||||||
11 | sum of $5,000,000 from the Public Aid Recoveries Trust Fund | ||||||
12 | (formerly the Public Assistance Recoveries Trust Fund) into | ||||||
13 | the DHS Recoveries Trust Fund. | ||||||
14 | (Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12; | ||||||
15 | 98-130, eff. 8-2-13; 98-651, eff. 6-16-14.) | ||||||
16 | (305 ILCS 5/12-10.4) | ||||||
17 | Sec. 12-10.4. Juvenile Rehabilitation Services Medicaid | ||||||
18 | Matching Fund. There is created in the State Treasury the | ||||||
19 | Juvenile Rehabilitation Services Medicaid Matching Fund. | ||||||
20 | Deposits to this Fund shall consist of all moneys received | ||||||
21 | from the federal government for behavioral health services | ||||||
22 | secured by counties pursuant to an agreement with the | ||||||
23 | Department of Healthcare and Family Services with respect to | ||||||
24 | Title XIX of the Social Security Act or under the Children's | ||||||
25 | Health Insurance Program pursuant to the Children's Health |
| |||||||
| |||||||
1 | Insurance Program Act and Title XXI of the Social Security Act | ||||||
2 | for minors who are committed to mental health facilities by | ||||||
3 | the Illinois court system and for residential placements | ||||||
4 | secured by the Department of Juvenile Justice for minors as a | ||||||
5 | condition of their aftercare release. | ||||||
6 | Disbursements from the Fund shall be made, subject to | ||||||
7 | appropriation, by the Department of Healthcare and Family | ||||||
8 | Services for grants to the Department of Juvenile Justice and | ||||||
9 | those counties which secure behavioral health services ordered | ||||||
10 | by the courts and which have an interagency agreement with the | ||||||
11 | Department and submit detailed bills according to standards | ||||||
12 | determined by the Department. | ||||||
13 | On January 1, 2026, or as soon thereafter as practical, | ||||||
14 | the State Comptroller shall direct and the State Treasurer | ||||||
15 | shall transfer the remaining balance from the Juvenile | ||||||
16 | Rehabilitation Services Medicaid Matching Fund into the Public | ||||||
17 | Aid Recoveries Trust Fund. Upon completion of the transfer, | ||||||
18 | the Juvenile Rehabilitation Services Medicaid Matching Fund is | ||||||
19 | dissolved, and any future deposits due to that Fund and any | ||||||
20 | outstanding obligations or liabilities of that Fund shall pass | ||||||
21 | to the Public Aid Recoveries Trust Fund. | ||||||
22 | (Source: P.A. 98-558, eff. 1-1-14.) | ||||||
23 | Article 140. | ||||||
24 | (30 ILCS 105/5.856 rep.) |
| |||||||
| |||||||
1 | Section 140-5. The State Finance Act is amended by | ||||||
2 | repealing Section 5.856. | ||||||
3 | (305 ILCS 5/Art. V-G rep.) | ||||||
4 | Section 140-10. The Illinois Public Aid Code is amended by | ||||||
5 | repealing Article V-G. | ||||||
6 | Article 145. | ||||||
7 | Section 145-5. The State Finance Act is amended by | ||||||
8 | changing Sections 5.409 and 6z-40 as follows: | ||||||
9 | (30 ILCS 105/5.409) | ||||||
10 | Sec. 5.409. The Provider Inquiry Trust Fund. This Section | ||||||
11 | is repealed on January 1, 2025. | ||||||
12 | (Source: P.A. 89-21, eff. 7-1-95.) | ||||||
13 | (30 ILCS 105/6z-40) | ||||||
14 | Sec. 6z-40. Provider Inquiry Trust Fund. The Provider | ||||||
15 | Inquiry Trust Fund is created as a special fund in the State | ||||||
16 | treasury. Payments into the fund shall consist of fees or | ||||||
17 | other moneys owed by providers of services or their agents, | ||||||
18 | including other State agencies, for access to and utilization | ||||||
19 | of Illinois Department of Healthcare and Family Services | ||||||
20 | Public Aid eligibility files to verify eligibility of clients, | ||||||
21 | bills for services, or other similar, related uses. |
| |||||||
| |||||||
1 | Disbursements from the fund shall consist of payments to the | ||||||
2 | Department of Innovation and Technology Central Management | ||||||
3 | Services for communication and statistical services and for | ||||||
4 | payments for administrative expenses incurred by the Illinois | ||||||
5 | Department of Healthcare and Family Services Public Aid in the | ||||||
6 | operation of the fund. | ||||||
7 | On January 1, 2025, or as soon thereafter as practical, | ||||||
8 | the State Comptroller shall direct and the State Treasurer | ||||||
9 | shall transfer the remaining balance from the Provider Inquiry | ||||||
10 | Trust Fund into the Healthcare Provider Relief Fund. Upon | ||||||
11 | completion of the transfer, the Provider Inquiry Trust Fund is | ||||||
12 | dissolved, and any future deposits due to that Fund and any | ||||||
13 | outstanding obligations or liabilities of that Fund shall pass | ||||||
14 | to the Healthcare Provider Relief Fund. | ||||||
15 | (Source: P.A. 94-91, eff. 7-1-05.) | ||||||
16 | ARTICLE 150. | ||||||
17 | Section 150-5. The Illinois Public Aid Code is amended by | ||||||
18 | changing Section 5-30.1 and by adding Section 5-30.18 as | ||||||
19 | follows: | ||||||
20 | (305 ILCS 5/5-30.1) | ||||||
21 | Sec. 5-30.1. Managed care protections. | ||||||
22 | (a) As used in this Section: | ||||||
23 | "Managed care organization" or "MCO" means any entity |
| |||||||
| |||||||
1 | which contracts with the Department to provide services where | ||||||
2 | payment for medical services is made on a capitated basis. | ||||||
3 | "Emergency services" means health care items and services, | ||||||
4 | including inpatient and outpatient hospital services, | ||||||
5 | furnished or required to evaluate and stabilize an emergency | ||||||
6 | medical condition. "Emergency services" include inpatient | ||||||
7 | stabilization services furnished during the inpatient | ||||||
8 | stabilization period. "Emergency services" do not include | ||||||
9 | post-stabilization medical services. include: | ||||||
10 | (1) emergency services, as defined by Section 10 of | ||||||
11 | the Managed Care Reform and Patient Rights Act; | ||||||
12 | (2) emergency medical screening examinations, as | ||||||
13 | defined by Section 10 of the Managed Care Reform and | ||||||
14 | Patient Rights Act; | ||||||
15 | (3) post-stabilization medical services, as defined by | ||||||
16 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
17 | Act; and | ||||||
18 | (4) emergency medical conditions, as defined by | ||||||
19 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
20 | Act. | ||||||
21 | "Emergency medical condition" means a medical condition | ||||||
22 | manifesting itself by acute symptoms of sufficient severity, | ||||||
23 | regardless of the final diagnosis given, such that a prudent | ||||||
24 | layperson, who possesses an average knowledge of health and | ||||||
25 | medicine, could reasonably expect the absence of immediate | ||||||
26 | medical attention to result in: |
| |||||||
| |||||||
1 | (1) placing the health of the individual (or, with | ||||||
2 | respect to a pregnant woman, the health of the woman or her | ||||||
3 | unborn child) in serious jeopardy; | ||||||
4 | (2) serious impairment to bodily functions; | ||||||
5 | (3) serious dysfunction of any bodily organ or part; | ||||||
6 | (4) inadequately controlled pain; or | ||||||
7 | (5) with respect to a pregnant woman who is having | ||||||
8 | contractions: | ||||||
9 | (A) inadequate time to complete a safe transfer to | ||||||
10 | another hospital before delivery; or | ||||||
11 | (B) a transfer to another hospital may pose a | ||||||
12 | threat to the health or safety of the woman or unborn | ||||||
13 | child. | ||||||
14 | "Emergency medical screening examination" means a medical | ||||||
15 | screening examination and evaluation by a physician licensed | ||||||
16 | to practice medicine in all its branches or, to the extent | ||||||
17 | permitted by applicable laws, by other appropriately licensed | ||||||
18 | personnel under the supervision of or in collaboration with a | ||||||
19 | physician licensed to practice medicine in all its branches to | ||||||
20 | determine whether the need for emergency services exists. | ||||||
21 | "Health care services" mean any medical or behavioral | ||||||
22 | health services covered under the medical assistance program | ||||||
23 | that are subject to review under a service authorization | ||||||
24 | program. | ||||||
25 | "Inpatient stabilization period" means the initial 72 | ||||||
26 | hours of inpatient stabilization services, beginning from the |
| |||||||
| |||||||
1 | date and time of the order for inpatient admission to the | ||||||
2 | hospital. | ||||||
3 | "Inpatient stabilization services" mean emergency services | ||||||
4 | furnished in the inpatient setting at a hospital pursuant to | ||||||
5 | an order for inpatient admission by a physician or other | ||||||
6 | qualified practitioner who has admitting privileges at the | ||||||
7 | hospital, as permitted by State law, to stabilize an emergency | ||||||
8 | medical condition following an emergency medical screening | ||||||
9 | examination. | ||||||
10 | "Post-stabilization medical services" means health care | ||||||
11 | services provided to an enrollee that are furnished in a | ||||||
12 | hospital by a provider that is qualified to furnish such | ||||||
13 | services and determined to be medically necessary by the | ||||||
14 | provider and directly related to the emergency medical | ||||||
15 | condition following stabilization. | ||||||
16 | "Provider" means a facility or individual who is actively | ||||||
17 | enrolled in the medical assistance program and licensed or | ||||||
18 | otherwise authorized to order, prescribe, refer, or render | ||||||
19 | health care services in this State. | ||||||
20 | "Service authorization determination" means a decision | ||||||
21 | made by a service authorization program in advance of, | ||||||
22 | concurrent to, or after the provision of a health care service | ||||||
23 | to approve, change the level of care, partially deny, deny, or | ||||||
24 | otherwise limit coverage and reimbursement for a health care | ||||||
25 | service upon review of a service authorization request. | ||||||
26 | "Service authorization program" means any utilization |
| |||||||
| |||||||
1 | review, utilization management, peer review, quality review, | ||||||
2 | or other medical management activity conducted by an MCO, or | ||||||
3 | its contracted utilization review organization, including, but | ||||||
4 | not limited to, prior authorization, prior approval, | ||||||
5 | pre-certification, concurrent review, retrospective review, or | ||||||
6 | certification of admission, of health care services provided | ||||||
7 | in the inpatient or outpatient hospital setting. | ||||||
8 | "Service authorization request" means a request by a | ||||||
9 | provider to a service authorization program to determine | ||||||
10 | whether a health care service meets the reimbursement | ||||||
11 | eligibility requirements for medically necessary, clinically | ||||||
12 | appropriate care, resulting in the issuance of a service | ||||||
13 | authorization determination. | ||||||
14 | "Utilization review organization" or "URO" means an MCO's | ||||||
15 | utilization review department or a peer review organization or | ||||||
16 | quality improvement organization that contracts with an MCO to | ||||||
17 | administer a service authorization program and make service | ||||||
18 | authorization determinations. | ||||||
19 | (b) As provided by Section 5-16.12, managed care | ||||||
20 | organizations are subject to the provisions of the Managed | ||||||
21 | Care Reform and Patient Rights Act. | ||||||
22 | (c) An MCO shall pay any provider of emergency services , | ||||||
23 | including for inpatient stabilization services provided during | ||||||
24 | the inpatient stabilization period, that does not have in | ||||||
25 | effect a contract with the contracted Medicaid MCO. The | ||||||
26 | default rate of reimbursement shall be the rate paid under |
| |||||||
| |||||||
1 | Illinois Medicaid fee-for-service program methodology, | ||||||
2 | including all policy adjusters, including but not limited to | ||||||
3 | Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
4 | Adjustments, Outpatient High Volume Adjustments, and all | ||||||
5 | outlier add-on adjustments to the extent such adjustments are | ||||||
6 | incorporated in the development of the applicable MCO | ||||||
7 | capitated rates. | ||||||
8 | (d) (Blank). An MCO shall pay for all post-stabilization | ||||||
9 | services as a covered service in any of the following | ||||||
10 | situations: | ||||||
11 | (1) the MCO authorized such services; | ||||||
12 | (2) such services were administered to maintain the | ||||||
13 | enrollee's stabilized condition within one hour after a | ||||||
14 | request to the MCO for authorization of further | ||||||
15 | post-stabilization services; | ||||||
16 | (3) the MCO did not respond to a request to authorize | ||||||
17 | such services within one hour; | ||||||
18 | (4) the MCO could not be contacted; or | ||||||
19 | (5) the MCO and the treating provider, if the treating | ||||||
20 | provider is a non-affiliated provider, could not reach an | ||||||
21 | agreement concerning the enrollee's care and an affiliated | ||||||
22 | provider was unavailable for a consultation, in which case | ||||||
23 | the MCO must pay for such services rendered by the | ||||||
24 | treating non-affiliated provider until an affiliated | ||||||
25 | provider was reached and either concurred with the | ||||||
26 | treating non-affiliated provider's plan of care or assumed |
| |||||||
| |||||||
1 | responsibility for the enrollee's care. Such payment shall | ||||||
2 | be made at the default rate of reimbursement paid under | ||||||
3 | Illinois Medicaid fee-for-service program methodology, | ||||||
4 | including all policy adjusters, including but not limited | ||||||
5 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
6 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
7 | outlier add-on adjustments to the extent that such | ||||||
8 | adjustments are incorporated in the development of the | ||||||
9 | applicable MCO capitated rates. | ||||||
10 | (e) Notwithstanding any other provision of law, the The | ||||||
11 | following requirements apply to MCOs in determining payment | ||||||
12 | for all emergency services , including inpatient stabilization | ||||||
13 | services provided during the inpatient stabilization period : | ||||||
14 | (1) The MCO MCOs shall not impose any service | ||||||
15 | authorization program requirements for prior approval of | ||||||
16 | emergency services , including, but not limited to, prior | ||||||
17 | authorization, prior approval, pre-certification, | ||||||
18 | certification of admission, concurrent review, or | ||||||
19 | retrospective review . | ||||||
20 | (A) Notification period: Hospitals shall notify | ||||||
21 | the enrollee's Medicaid MCO within 48 hours of the | ||||||
22 | date and time the order for inpatient admission is | ||||||
23 | written. Notification shall be limited to advising the | ||||||
24 | MCO that the patient has been admitted to a hospital | ||||||
25 | inpatient level of care. | ||||||
26 | (B) If the admitting hospital complies with the |
| |||||||
| |||||||
1 | notification provisions of subparagraph (A), the | ||||||
2 | Medicaid MCO may not initiate concurrent review before | ||||||
3 | the end of the inpatient stabilization period. If the | ||||||
4 | admitting hospital does not comply with the | ||||||
5 | notification requirements in subparagraph (A), the | ||||||
6 | Medicaid MCO may initiate concurrent review for the | ||||||
7 | continuation of the stay beginning at the end of the | ||||||
8 | 48-hour notification period. | ||||||
9 | (C) Coverage for services provided during the | ||||||
10 | 48-hour notification period may not be retrospectively | ||||||
11 | denied. | ||||||
12 | (2) The MCO shall cover emergency services provided to | ||||||
13 | enrollees who are temporarily away from their residence | ||||||
14 | and outside the contracting area to the extent that the | ||||||
15 | enrollees would be entitled to the emergency services if | ||||||
16 | they still were within the contracting area. | ||||||
17 | (3) The MCO shall have no obligation to cover | ||||||
18 | emergency medical services provided on an emergency basis | ||||||
19 | that are not covered services under the contract between | ||||||
20 | the MCO and the Department . | ||||||
21 | (4) The MCO shall not condition coverage for emergency | ||||||
22 | services on the treating provider notifying the MCO of the | ||||||
23 | enrollee's emergency medical screening examination and | ||||||
24 | treatment within 10 days after presentation for emergency | ||||||
25 | services. | ||||||
26 | (5) The determination of the attending emergency |
| |||||||
| |||||||
1 | physician, or the practitioner responsible for the | ||||||
2 | enrollee's care at the hospital the provider actually | ||||||
3 | treating the enrollee , of whether an enrollee requires | ||||||
4 | inpatient stabilization services, can be stabilized in the | ||||||
5 | outpatient setting, or is sufficiently stabilized for | ||||||
6 | discharge or transfer to another setting facility , shall | ||||||
7 | be binding on the MCO. The MCO shall cover and reimburse | ||||||
8 | providers for emergency services as billed by the provider | ||||||
9 | for all enrollees whether the emergency services are | ||||||
10 | provided by an affiliated or non-affiliated provider , | ||||||
11 | except in cases of fraud. The MCO shall reimburse | ||||||
12 | inpatient stabilization services provided during the | ||||||
13 | inpatient stabilization period and billed as inpatient | ||||||
14 | level of care based on the appropriate inpatient | ||||||
15 | reimbursement methodology . | ||||||
16 | (6) The MCO's financial responsibility for | ||||||
17 | post-stabilization medical care services it has not | ||||||
18 | pre-approved ends when: | ||||||
19 | (A) a plan physician with privileges at the | ||||||
20 | treating hospital assumes responsibility for the | ||||||
21 | enrollee's care; | ||||||
22 | (B) a plan physician assumes responsibility for | ||||||
23 | the enrollee's care through transfer; | ||||||
24 | (C) a contracting entity representative and the | ||||||
25 | treating physician reach an agreement concerning the | ||||||
26 | enrollee's care; or |
| |||||||
| |||||||
1 | (D) the enrollee is discharged. | ||||||
2 | (e-5) An MCO shall pay for all post-stabilization medical | ||||||
3 | services as a covered service in any of the following | ||||||
4 | situations: | ||||||
5 | (1) the MCO or its URO authorized such services; | ||||||
6 | (2) such services were administered to maintain the | ||||||
7 | enrollee's stabilized condition within one hour after a | ||||||
8 | request to the MCO for authorization of further | ||||||
9 | post-stabilization services; | ||||||
10 | (3) the MCO or its URO did not respond to a request to | ||||||
11 | authorize such services within one hour; | ||||||
12 | (4) the MCO or its URO could not be contacted; or | ||||||
13 | (5) the MCO or its URO and the treating provider, if | ||||||
14 | the treating provider is a non-affiliated provider, could | ||||||
15 | not reach an agreement concerning the enrollee's care and | ||||||
16 | an affiliated provider was unavailable for a consultation, | ||||||
17 | in which case the MCO must pay for such services rendered | ||||||
18 | by the treating non-affiliated provider until an | ||||||
19 | affiliated provider was reached and either concurred with | ||||||
20 | the treating non-affiliated provider's plan of care or | ||||||
21 | assumed responsibility for the enrollee's care. Such | ||||||
22 | payment shall be made at the default rate of reimbursement | ||||||
23 | paid under the State's Medicaid fee-for-service program | ||||||
24 | methodology, including all policy adjusters, including, | ||||||
25 | but not limited to, Medicaid High Volume Adjustments, | ||||||
26 | Medicaid Percentage Adjustments, Outpatient High Volume |
| |||||||
| |||||||
1 | Adjustments, and all outlier add-on adjustments to the | ||||||
2 | extent that such adjustments are incorporated in the | ||||||
3 | development of the applicable MCO capitated rates. | ||||||
4 | (f) Network adequacy and transparency. | ||||||
5 | (1) The Department shall: | ||||||
6 | (A) ensure that an adequate provider network is in | ||||||
7 | place, taking into consideration health professional | ||||||
8 | shortage areas and medically underserved areas; | ||||||
9 | (B) publicly release an explanation of its process | ||||||
10 | for analyzing network adequacy; | ||||||
11 | (C) periodically ensure that an MCO continues to | ||||||
12 | have an adequate network in place; | ||||||
13 | (D) require MCOs, including Medicaid Managed Care | ||||||
14 | Entities as defined in Section 5-30.2, to meet | ||||||
15 | provider directory requirements under Section 5-30.3; | ||||||
16 | (E) require MCOs to ensure that any | ||||||
17 | Medicaid-certified provider under contract with an MCO | ||||||
18 | and previously submitted on a roster on the date of | ||||||
19 | service is paid for any medically necessary, | ||||||
20 | Medicaid-covered, and authorized service rendered to | ||||||
21 | any of the MCO's enrollees, regardless of inclusion on | ||||||
22 | the MCO's published and publicly available directory | ||||||
23 | of available providers; and | ||||||
24 | (F) require MCOs, including Medicaid Managed Care | ||||||
25 | Entities as defined in Section 5-30.2, to meet each of | ||||||
26 | the requirements under subsection (d-5) of Section 10 |
| |||||||
| |||||||
1 | of the Network Adequacy and Transparency Act; with | ||||||
2 | necessary exceptions to the MCO's network to ensure | ||||||
3 | that admission and treatment with a provider or at a | ||||||
4 | treatment facility in accordance with the network | ||||||
5 | adequacy standards in paragraph (3) of subsection | ||||||
6 | (d-5) of Section 10 of the Network Adequacy and | ||||||
7 | Transparency Act is limited to providers or facilities | ||||||
8 | that are Medicaid certified. | ||||||
9 | (2) Each MCO shall confirm its receipt of information | ||||||
10 | submitted specific to physician or dentist additions or | ||||||
11 | physician or dentist deletions from the MCO's provider | ||||||
12 | network within 3 days after receiving all required | ||||||
13 | information from contracted physicians or dentists, and | ||||||
14 | electronic physician and dental directories must be | ||||||
15 | updated consistent with current rules as published by the | ||||||
16 | Centers for Medicare and Medicaid Services or its | ||||||
17 | successor agency. | ||||||
18 | (g) Timely payment of claims. | ||||||
19 | (1) The MCO shall pay a claim within 30 days of | ||||||
20 | receiving a claim that contains all the essential | ||||||
21 | information needed to adjudicate the claim. | ||||||
22 | (2) The MCO shall notify the billing party of its | ||||||
23 | inability to adjudicate a claim within 30 days of | ||||||
24 | receiving that claim. | ||||||
25 | (3) The MCO shall pay a penalty that is at least equal | ||||||
26 | to the timely payment interest penalty imposed under |
| |||||||
| |||||||
1 | Section 368a of the Illinois Insurance Code for any claims | ||||||
2 | not timely paid. | ||||||
3 | (A) When an MCO is required to pay a timely payment | ||||||
4 | interest penalty to a provider, the MCO must calculate | ||||||
5 | and pay the timely payment interest penalty that is | ||||||
6 | due to the provider within 30 days after the payment of | ||||||
7 | the claim. In no event shall a provider be required to | ||||||
8 | request or apply for payment of any owed timely | ||||||
9 | payment interest penalties. | ||||||
10 | (B) Such payments shall be reported separately | ||||||
11 | from the claim payment for services rendered to the | ||||||
12 | MCO's enrollee and clearly identified as interest | ||||||
13 | payments. | ||||||
14 | (4)(A) The Department shall require MCOs to expedite | ||||||
15 | payments to providers identified on the Department's | ||||||
16 | expedited provider list, determined in accordance with 89 | ||||||
17 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
18 | frequently as the providers are paid under the | ||||||
19 | Department's fee-for-service expedited provider schedule. | ||||||
20 | (B) Compliance with the expedited provider requirement | ||||||
21 | may be satisfied by an MCO through the use of a Periodic | ||||||
22 | Interim Payment (PIP) program that has been mutually | ||||||
23 | agreed to and documented between the MCO and the provider, | ||||||
24 | if the PIP program ensures that any expedited provider | ||||||
25 | receives regular and periodic payments based on prior | ||||||
26 | period payment experience from that MCO. Total payments |
| |||||||
| |||||||
1 | under the PIP program may be reconciled against future PIP | ||||||
2 | payments on a schedule mutually agreed to between the MCO | ||||||
3 | and the provider. | ||||||
4 | (C) The Department shall share at least monthly its | ||||||
5 | expedited provider list and the frequency with which it | ||||||
6 | pays providers on the expedited list. | ||||||
7 | (g-5) Recognizing that the rapid transformation of the | ||||||
8 | Illinois Medicaid program may have unintended operational | ||||||
9 | challenges for both payers and providers: | ||||||
10 | (1) in no instance shall a medically necessary covered | ||||||
11 | service rendered in good faith, based upon eligibility | ||||||
12 | information documented by the provider, be denied coverage | ||||||
13 | or diminished in payment amount if the eligibility or | ||||||
14 | coverage information available at the time the service was | ||||||
15 | rendered is later found to be inaccurate in the assignment | ||||||
16 | of coverage responsibility between MCOs or the | ||||||
17 | fee-for-service system, except for instances when an | ||||||
18 | individual is deemed to have not been eligible for | ||||||
19 | coverage under the Illinois Medicaid program; and | ||||||
20 | (2) the Department shall, by December 31, 2016, adopt | ||||||
21 | rules establishing policies that shall be included in the | ||||||
22 | Medicaid managed care policy and procedures manual | ||||||
23 | addressing payment resolutions in situations in which a | ||||||
24 | provider renders services based upon information obtained | ||||||
25 | after verifying a patient's eligibility and coverage plan | ||||||
26 | through either the Department's current enrollment system |
| |||||||
| |||||||
1 | or a system operated by the coverage plan identified by | ||||||
2 | the patient presenting for services: | ||||||
3 | (A) such medically necessary covered services | ||||||
4 | shall be considered rendered in good faith; | ||||||
5 | (B) such policies and procedures shall be | ||||||
6 | developed in consultation with industry | ||||||
7 | representatives of the Medicaid managed care health | ||||||
8 | plans and representatives of provider associations | ||||||
9 | representing the majority of providers within the | ||||||
10 | identified provider industry; and | ||||||
11 | (C) such rules shall be published for a review and | ||||||
12 | comment period of no less than 30 days on the | ||||||
13 | Department's website with final rules remaining | ||||||
14 | available on the Department's website. | ||||||
15 | The rules on payment resolutions shall include, but | ||||||
16 | not be limited to: | ||||||
17 | (A) the extension of the timely filing period; | ||||||
18 | (B) retroactive prior authorizations; and | ||||||
19 | (C) guaranteed minimum payment rate of no less | ||||||
20 | than the current, as of the date of service, | ||||||
21 | fee-for-service rate, plus all applicable add-ons, | ||||||
22 | when the resulting service relationship is out of | ||||||
23 | network. | ||||||
24 | The rules shall be applicable for both MCO coverage | ||||||
25 | and fee-for-service coverage. | ||||||
26 | If the fee-for-service system is ultimately determined to |
| |||||||
| |||||||
1 | have been responsible for coverage on the date of service, the | ||||||
2 | Department shall provide for an extended period for claims | ||||||
3 | submission outside the standard timely filing requirements. | ||||||
4 | (g-6) MCO Performance Metrics Report. | ||||||
5 | (1) The Department shall publish, on at least a | ||||||
6 | quarterly basis, each MCO's operational performance, | ||||||
7 | including, but not limited to, the following categories of | ||||||
8 | metrics: | ||||||
9 | (A) claims payment, including timeliness and | ||||||
10 | accuracy; | ||||||
11 | (B) prior authorizations; | ||||||
12 | (C) grievance and appeals; | ||||||
13 | (D) utilization statistics; | ||||||
14 | (E) provider disputes; | ||||||
15 | (F) provider credentialing; and | ||||||
16 | (G) member and provider customer service. | ||||||
17 | (2) The Department shall ensure that the metrics | ||||||
18 | report is accessible to providers online by January 1, | ||||||
19 | 2017. | ||||||
20 | (3) The metrics shall be developed in consultation | ||||||
21 | with industry representatives of the Medicaid managed care | ||||||
22 | health plans and representatives of associations | ||||||
23 | representing the majority of providers within the | ||||||
24 | identified industry. | ||||||
25 | (4) Metrics shall be defined and incorporated into the | ||||||
26 | applicable Managed Care Policy Manual issued by the |
| |||||||
| |||||||
1 | Department. | ||||||
2 | (g-7) MCO claims processing and performance analysis. In | ||||||
3 | order to monitor MCO payments to hospital providers, pursuant | ||||||
4 | to Public Act 100-580, the Department shall post an analysis | ||||||
5 | of MCO claims processing and payment performance on its | ||||||
6 | website every 6 months. Such analysis shall include a review | ||||||
7 | and evaluation of a representative sample of hospital claims | ||||||
8 | that are rejected and denied for clean and unclean claims and | ||||||
9 | the top 5 reasons for such actions and timeliness of claims | ||||||
10 | adjudication, which identifies the percentage of claims | ||||||
11 | adjudicated within 30, 60, 90, and over 90 days, and the dollar | ||||||
12 | amounts associated with those claims. | ||||||
13 | (g-8) Dispute resolution process. The Department shall | ||||||
14 | maintain a provider complaint portal through which a provider | ||||||
15 | can submit to the Department unresolved disputes with an MCO. | ||||||
16 | An unresolved dispute means an MCO's decision that denies in | ||||||
17 | whole or in part a claim for reimbursement to a provider for | ||||||
18 | health care services rendered by the provider to an enrollee | ||||||
19 | of the MCO with which the provider disagrees. Disputes shall | ||||||
20 | not be submitted to the portal until the provider has availed | ||||||
21 | itself of the MCO's internal dispute resolution process. | ||||||
22 | Disputes that are submitted to the MCO internal dispute | ||||||
23 | resolution process may be submitted to the Department of | ||||||
24 | Healthcare and Family Services' complaint portal no sooner | ||||||
25 | than 30 days after submitting to the MCO's internal process | ||||||
26 | and not later than 30 days after the unsatisfactory resolution |
| |||||||
| |||||||
1 | of the internal MCO process or 60 days after submitting the | ||||||
2 | dispute to the MCO internal process. Multiple claim disputes | ||||||
3 | involving the same MCO may be submitted in one complaint, | ||||||
4 | regardless of whether the claims are for different enrollees, | ||||||
5 | when the specific reason for non-payment of the claims | ||||||
6 | involves a common question of fact or policy. Within 10 | ||||||
7 | business days of receipt of a complaint, the Department shall | ||||||
8 | present such disputes to the appropriate MCO, which shall then | ||||||
9 | have 30 days to issue its written proposal to resolve the | ||||||
10 | dispute. The Department may grant one 30-day extension of this | ||||||
11 | time frame to one of the parties to resolve the dispute. If the | ||||||
12 | dispute remains unresolved at the end of this time frame or the | ||||||
13 | provider is not satisfied with the MCO's written proposal to | ||||||
14 | resolve the dispute, the provider may, within 30 days, request | ||||||
15 | the Department to review the dispute and make a final | ||||||
16 | determination. Within 30 days of the request for Department | ||||||
17 | review of the dispute, both the provider and the MCO shall | ||||||
18 | present all relevant information to the Department for | ||||||
19 | resolution and make individuals with knowledge of the issues | ||||||
20 | available to the Department for further inquiry if needed. | ||||||
21 | Within 30 days of receiving the relevant information on the | ||||||
22 | dispute, or the lapse of the period for submitting such | ||||||
23 | information, the Department shall issue a written decision on | ||||||
24 | the dispute based on contractual terms between the provider | ||||||
25 | and the MCO, contractual terms between the MCO and the | ||||||
26 | Department of Healthcare and Family Services and applicable |
| |||||||
| |||||||
1 | Medicaid policy. The decision of the Department shall be | ||||||
2 | final. By January 1, 2020, the Department shall establish by | ||||||
3 | rule further details of this dispute resolution process. | ||||||
4 | Disputes between MCOs and providers presented to the | ||||||
5 | Department for resolution are not contested cases, as defined | ||||||
6 | in Section 1-30 of the Illinois Administrative Procedure Act, | ||||||
7 | conferring any right to an administrative hearing. | ||||||
8 | (g-9)(1) The Department shall publish annually on its | ||||||
9 | website a report on the calculation of each managed care | ||||||
10 | organization's medical loss ratio showing the following: | ||||||
11 | (A) Premium revenue, with appropriate adjustments. | ||||||
12 | (B) Benefit expense, setting forth the aggregate | ||||||
13 | amount spent for the following: | ||||||
14 | (i) Direct paid claims. | ||||||
15 | (ii) Subcapitation payments. | ||||||
16 | (iii) Other claim payments. | ||||||
17 | (iv) Direct reserves. | ||||||
18 | (v) Gross recoveries. | ||||||
19 | (vi) Expenses for activities that improve health | ||||||
20 | care quality as allowed by the Department. | ||||||
21 | (2) The medical loss ratio shall be calculated consistent | ||||||
22 | with federal law and regulation following a claims runout | ||||||
23 | period determined by the Department. | ||||||
24 | (g-10)(1) "Liability effective date" means the date on | ||||||
25 | which an MCO becomes responsible for payment for medically | ||||||
26 | necessary and covered services rendered by a provider to one |
| |||||||
| |||||||
1 | of its enrollees in accordance with the contract terms between | ||||||
2 | the MCO and the provider. The liability effective date shall | ||||||
3 | be the later of: | ||||||
4 | (A) The execution date of a network participation | ||||||
5 | contract agreement. | ||||||
6 | (B) The date the provider or its representative | ||||||
7 | submits to the MCO the complete and accurate standardized | ||||||
8 | roster form for the provider in the format approved by the | ||||||
9 | Department. | ||||||
10 | (C) The provider effective date contained within the | ||||||
11 | Department's provider enrollment subsystem within the | ||||||
12 | Illinois Medicaid Program Advanced Cloud Technology | ||||||
13 | (IMPACT) System. | ||||||
14 | (2) The standardized roster form may be submitted to the | ||||||
15 | MCO at the same time that the provider submits an enrollment | ||||||
16 | application to the Department through IMPACT. | ||||||
17 | (3) By October 1, 2019, the Department shall require all | ||||||
18 | MCOs to update their provider directory with information for | ||||||
19 | new practitioners of existing contracted providers within 30 | ||||||
20 | days of receipt of a complete and accurate standardized roster | ||||||
21 | template in the format approved by the Department provided | ||||||
22 | that the provider is effective in the Department's provider | ||||||
23 | enrollment subsystem within the IMPACT system. Such provider | ||||||
24 | directory shall be readily accessible for purposes of | ||||||
25 | selecting an approved health care provider and comply with all | ||||||
26 | other federal and State requirements. |
| |||||||
| |||||||
1 | (g-11) The Department shall work with relevant | ||||||
2 | stakeholders on the development of operational guidelines to | ||||||
3 | enhance and improve operational performance of Illinois' | ||||||
4 | Medicaid managed care program, including, but not limited to, | ||||||
5 | improving provider billing practices, reducing claim | ||||||
6 | rejections and inappropriate payment denials, and | ||||||
7 | standardizing processes, procedures, definitions, and response | ||||||
8 | timelines, with the goal of reducing provider and MCO | ||||||
9 | administrative burdens and conflict. The Department shall | ||||||
10 | include a report on the progress of these program improvements | ||||||
11 | and other topics in its Fiscal Year 2020 annual report to the | ||||||
12 | General Assembly. | ||||||
13 | (g-12) Notwithstanding any other provision of law, if the | ||||||
14 | Department or an MCO requires submission of a claim for | ||||||
15 | payment in a non-electronic format, a provider shall always be | ||||||
16 | afforded a period of no less than 90 business days, as a | ||||||
17 | correction period, following any notification of rejection by | ||||||
18 | either the Department or the MCO to correct errors or | ||||||
19 | omissions in the original submission. | ||||||
20 | Under no circumstances, either by an MCO or under the | ||||||
21 | State's fee-for-service system, shall a provider be denied | ||||||
22 | payment for failure to comply with any timely submission | ||||||
23 | requirements under this Code or under any existing contract, | ||||||
24 | unless the non-electronic format claim submission occurs after | ||||||
25 | the initial 180 days following the latest date of service on | ||||||
26 | the claim, or after the 90 business days correction period |
| |||||||
| |||||||
1 | following notification to the provider of rejection or denial | ||||||
2 | of payment. | ||||||
3 | (g-13) Utilization Review Standardization and | ||||||
4 | Transparency. | ||||||
5 | (1) To ensure greater standardization and transparency | ||||||
6 | related to service authorization determinations, for all | ||||||
7 | individuals covered under the medical assistance program, | ||||||
8 | including both the fee-for-service and managed care | ||||||
9 | programs, the Department shall, in consultation with the | ||||||
10 | MCOs, a statewide association representing the MCOs, a | ||||||
11 | statewide association representing the majority of | ||||||
12 | Illinois hospitals, a statewide association representing | ||||||
13 | physicians, or any other interested parties deemed | ||||||
14 | appropriate by the Department, adopt administrative rules | ||||||
15 | consistent with this subsection, in accordance with the | ||||||
16 | Illinois Administrative Procedure Act. | ||||||
17 | (2) Prior to July 1, 2025, the Department shall in | ||||||
18 | accordance with the Illinois Administrative Procedure Act | ||||||
19 | adopt rules which govern MCO practices for dates of | ||||||
20 | services on and after July 1, 2025, as follows: | ||||||
21 | (A) guidelines related to the publication of MCO | ||||||
22 | authorization policies; | ||||||
23 | (B) procedures that, due to medical complexity, | ||||||
24 | must be reimbursed under the applicable inpatient | ||||||
25 | methodology, when provided in the inpatient setting | ||||||
26 | and billed as an inpatient service; |
| |||||||
| |||||||
1 | (C) standardization of administrative forms used | ||||||
2 | in the member appeal process; | ||||||
3 | (D) limitations on second or subsequent medical | ||||||
4 | necessity review of a health care service already | ||||||
5 | authorized by the MCO or URO under a service | ||||||
6 | authorization program; | ||||||
7 | (E) standardization of peer-to-peer processes and | ||||||
8 | timelines; | ||||||
9 | (F) defined criteria for urgent and standard | ||||||
10 | post-acute care service authorization requests; and | ||||||
11 | (G) standardized criteria for service | ||||||
12 | authorization programs for authorization of admission | ||||||
13 | to a long-term acute care hospital. | ||||||
14 | (3) The Department shall expand the scope of the | ||||||
15 | quality and compliance audits conducted by its contracted | ||||||
16 | external quality review organization to include, but not | ||||||
17 | be limited to: | ||||||
18 | (A) an analysis of the Medicaid MCO's compliance | ||||||
19 | with nationally recognized clinical decision | ||||||
20 | guidelines; | ||||||
21 | (B) an analysis that compares and contrasts the | ||||||
22 | Medicaid MCO's service authorization determination | ||||||
23 | outcomes to the outcomes of each other MCO plan and the | ||||||
24 | State's fee-for-service program model to evaluate | ||||||
25 | whether service authorization determinations are being | ||||||
26 | made consistently by all Medicaid MCOs to ensure that |
| |||||||
| |||||||
1 | all individuals are being treated in accordance with | ||||||
2 | equitable standards of care; | ||||||
3 | (C) an analysis, for each Medicaid MCO, of the | ||||||
4 | number of service authorization requests, including | ||||||
5 | requests for concurrent review and certification of | ||||||
6 | admissions, received, initially denied, overturned | ||||||
7 | through any post-denial process including, but not | ||||||
8 | limited to, enrollee or provider appeal, peer-to-peer | ||||||
9 | review, or the provider dispute resolution process, | ||||||
10 | denied but approved for a lower or different level of | ||||||
11 | care, and the number denied on final determination; | ||||||
12 | and | ||||||
13 | (D) provide a written report to the General | ||||||
14 | Assembly, detailing the items listed in this | ||||||
15 | subsection and any other metrics deemed necessary by | ||||||
16 | the Department, by the second April, following the | ||||||
17 | effective date of this amendatory Act of the 103rd | ||||||
18 | General Assembly, and each April thereafter. The | ||||||
19 | Department shall make this report available within 30 | ||||||
20 | days of delivery to the General Assembly, on its | ||||||
21 | public facing website. | ||||||
22 | (h) The Department shall not expand mandatory MCO | ||||||
23 | enrollment into new counties beyond those counties already | ||||||
24 | designated by the Department as of June 1, 2014 for the | ||||||
25 | individuals whose eligibility for medical assistance is not | ||||||
26 | the seniors or people with disabilities population until the |
| |||||||
| |||||||
1 | Department provides an opportunity for accountable care | ||||||
2 | entities and MCOs to participate in such newly designated | ||||||
3 | counties. | ||||||
4 | (h-5) Leading indicator data sharing. By January 1, 2024, | ||||||
5 | the Department shall obtain input from the Department of Human | ||||||
6 | Services, the Department of Juvenile Justice, the Department | ||||||
7 | of Children and Family Services, the State Board of Education, | ||||||
8 | managed care organizations, providers, and clinical experts to | ||||||
9 | identify and analyze key indicators from assessments and data | ||||||
10 | sets available to the Department that can be shared with | ||||||
11 | managed care organizations and similar care coordination | ||||||
12 | entities contracted with the Department as leading indicators | ||||||
13 | for elevated behavioral health crisis risk for children. To | ||||||
14 | the extent permitted by State and federal law, the identified | ||||||
15 | leading indicators shall be shared with managed care | ||||||
16 | organizations and similar care coordination entities | ||||||
17 | contracted with the Department within 6 months of | ||||||
18 | identification for the purpose of improving care coordination | ||||||
19 | with the early detection of elevated risk. Leading indicators | ||||||
20 | shall be reassessed annually with stakeholder input. | ||||||
21 | (i) The requirements of this Section apply to contracts | ||||||
22 | with accountable care entities and MCOs entered into, amended, | ||||||
23 | or renewed after June 16, 2014 (the effective date of Public | ||||||
24 | Act 98-651). | ||||||
25 | (j) Health care information released to managed care | ||||||
26 | organizations. A health care provider shall release to a |
| |||||||
| |||||||
1 | Medicaid managed care organization, upon request, and subject | ||||||
2 | to the Health Insurance Portability and Accountability Act of | ||||||
3 | 1996 and any other law applicable to the release of health | ||||||
4 | information, the health care information of the MCO's | ||||||
5 | enrollee, if the enrollee has completed and signed a general | ||||||
6 | release form that grants to the health care provider | ||||||
7 | permission to release the recipient's health care information | ||||||
8 | to the recipient's insurance carrier. | ||||||
9 | (k) The Department of Healthcare and Family Services, | ||||||
10 | managed care organizations, a statewide organization | ||||||
11 | representing hospitals, and a statewide organization | ||||||
12 | representing safety-net hospitals shall explore ways to | ||||||
13 | support billing departments in safety-net hospitals. | ||||||
14 | (l) The requirements of this Section added by Public Act | ||||||
15 | 102-4 shall apply to services provided on or after the first | ||||||
16 | day of the month that begins 60 days after April 27, 2021 (the | ||||||
17 | effective date of Public Act 102-4). | ||||||
18 | (m) Except where otherwise expressly specified, the | ||||||
19 | requirements of this Section added by this amendatory Act of | ||||||
20 | the 103rd General Assembly shall apply to services provided on | ||||||
21 | or after July 1, 2025. | ||||||
22 | (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; | ||||||
23 | 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. | ||||||
24 | 5-13-22; 103-546, eff. 8-11-23.) | ||||||
25 | (305 ILCS 5/5-30.18 new) |
| |||||||
| |||||||
1 | Sec. 5-30.18. Service authorization program performance. | ||||||
2 | (a) Definitions. As used in this Section: | ||||||
3 | "Gold Card provider" means a provider identified by each | ||||||
4 | Medicaid Managed Care Organization (MCO) as qualified under | ||||||
5 | the guidelines outlined by the Department in accordance with | ||||||
6 | subsection (c) and thereby granted a service authorization | ||||||
7 | exemption when ordering a health care service. | ||||||
8 | "Health care service" means any medical or behavioral | ||||||
9 | health service covered under the medical assistance program | ||||||
10 | that is rendered in the inpatient or outpatient hospital | ||||||
11 | setting, including hospital-based clinics, and subject to | ||||||
12 | review under a service authorization program. | ||||||
13 | "Provider" means an individual actively enrolled in the | ||||||
14 | medical assistance program and licensed or otherwise | ||||||
15 | authorized to order, prescribe, refer, or render health care | ||||||
16 | services in this State, and, as determined by the Department, | ||||||
17 | may also include hospitals that submit service authorization | ||||||
18 | requests. | ||||||
19 | "Service authorization exemption" means an exception | ||||||
20 | granted by a Medicaid MCO to a provider under which all service | ||||||
21 | authorization requests for covered health care services, | ||||||
22 | excluding pharmacy services and durable medical equipment, are | ||||||
23 | automatically deemed to be medically necessary, clinically | ||||||
24 | appropriate, and approved for reimbursement as ordered. | ||||||
25 | "Service authorization program" means any utilization | ||||||
26 | review, utilization management, peer review, quality review, |
| |||||||
| |||||||
1 | or other medical management activity conducted in advance of, | ||||||
2 | concurrent to, or after the provision of a health care service | ||||||
3 | by a Medicaid MCO, either directly or through a contracted | ||||||
4 | utilization review organization (URO), including, but not | ||||||
5 | limited to, prior authorization, pre-certification, | ||||||
6 | certification of admission, concurrent review, and | ||||||
7 | retrospective review of health care services. | ||||||
8 | "Service authorization request" means a request by a | ||||||
9 | provider to a service authorization program to determine | ||||||
10 | whether a health care service that is otherwise covered under | ||||||
11 | the medical assistance program meets the reimbursement | ||||||
12 | requirements established by the Medicaid MCO, or its | ||||||
13 | contracted URO, for medically necessary, clinically | ||||||
14 | appropriate care and to issue a service authorization | ||||||
15 | determination. | ||||||
16 | "Utilization review organization" or "URO" means a managed | ||||||
17 | care organization or other entity that has established or | ||||||
18 | administers one or more service authorization programs. | ||||||
19 | (b) In consultation with the Medicaid MCOs, a statewide | ||||||
20 | association representing managed care organizations, a | ||||||
21 | statewide association representing the majority of Illinois | ||||||
22 | hospitals, and a statewide association representing | ||||||
23 | physicians, the Department shall in accordance with the | ||||||
24 | Illinois Administrative Procedure Act, adopt administrative | ||||||
25 | rules, consistent with this Section, to require each Medicaid | ||||||
26 | MCO to identify Gold Card providers with such identification |
| |||||||
| |||||||
1 | initially being effective for health care services provided on | ||||||
2 | and after July 1, 2025. | ||||||
3 | (c) The Department shall adopt rules, in accordance with | ||||||
4 | the Illinois Administrative Procedure Act, to implement this | ||||||
5 | Section that include, but are not limited to, the following | ||||||
6 | provisions: | ||||||
7 | (1) Require each Medicaid MCO to provide a service | ||||||
8 | authorization exemption to a provider if the provider has | ||||||
9 | submitted at least 50 service authorization requests to | ||||||
10 | its service authorization program in the preceding | ||||||
11 | calendar year and the service authorization program | ||||||
12 | approved at least 90% of all service authorization | ||||||
13 | requests, regardless of the type of health care services | ||||||
14 | requested. | ||||||
15 | (2) Require that service authorization exemptions be | ||||||
16 | limited to services provided in an inpatient or outpatient | ||||||
17 | hospital setting inclusive of hospital-based clinics. | ||||||
18 | Service authorization exemptions under this Section shall | ||||||
19 | not pertain to pharmacy services and durable medical | ||||||
20 | equipment and supplies. | ||||||
21 | (3) The service authorization exemption shall be valid | ||||||
22 | for at least one year, shall be made by each Medicaid MCO | ||||||
23 | or its URO, and shall be binding on the Medicaid MCO and | ||||||
24 | its URO. | ||||||
25 | (4) The provider shall be required to continue to | ||||||
26 | document medically necessary, clinically appropriate care |
| |||||||
| |||||||
1 | and submit such documentation to the Medicaid MCO for the | ||||||
2 | purpose of continuous performance monitoring. If a | ||||||
3 | provider fails to maintain the 90% service authorization | ||||||
4 | standard, as determined on no more frequent a basis than | ||||||
5 | bi-annually, the provider's service authorization | ||||||
6 | exemption is subject to temporary or permanent suspension. | ||||||
7 | (5) Require that each Medicaid MCO publish on its | ||||||
8 | provider portal a list of all providers that have | ||||||
9 | qualified for a service authorization exemption or | ||||||
10 | indicate that a provider has qualified for a service | ||||||
11 | authorization exemption on its provider-facing provider | ||||||
12 | roster. | ||||||
13 | (6) Require that no later than December 1 of each | ||||||
14 | calendar year, each Medicaid MCO shall provide written | ||||||
15 | notification to all providers who qualify for a service | ||||||
16 | authorization exemption, for the subsequent calendar year. | ||||||
17 | (7) Require that each Medicaid MCO or its URO use the | ||||||
18 | policies and guidelines published by the Department to | ||||||
19 | evaluate whether a provider meets the criteria to qualify | ||||||
20 | for a service authorization exemption and the conditions | ||||||
21 | under which a service authorization exemption may be | ||||||
22 | rescinded, including review of the provider's service | ||||||
23 | authorization determinations during the preceding calendar | ||||||
24 | year. | ||||||
25 | (8) Require each Medicaid MCO to provide the | ||||||
26 | Department a list of all providers who were denied a |
| |||||||
| |||||||
1 | service authorization exemption or had a previously | ||||||
2 | granted service authorization exemption suspended, with | ||||||
3 | such denials being subject to an annual audit conducted by | ||||||
4 | an independent third-party URO to ensure their | ||||||
5 | appropriateness. | ||||||
6 | (A) The independent third-party URO shall issue a | ||||||
7 | written report consistent with this paragraph. | ||||||
8 | (B) The independent third-party URO shall not be | ||||||
9 | owned by, affiliated with, or employed by any Medicaid | ||||||
10 | MCO or its contracted URO, nor shall it have any | ||||||
11 | financial interest in the Medicaid MCO's service | ||||||
12 | authorization exemption program. | ||||||
13 | (d) Each Medicaid MCO must have a standard method to | ||||||
14 | accept and process professional claims and facility claims, as | ||||||
15 | billed by the provider, for a health care service that is | ||||||
16 | rendered, prescribed, or ordered by a provider granted a | ||||||
17 | service authorization exemption, except in cases of fraud. | ||||||
18 | (e) A service authorization program shall not deny, | ||||||
19 | partially deny, reduce the level of care, or otherwise limit | ||||||
20 | reimbursement to the rendering or supervising provider, | ||||||
21 | including the rendering facility, for health care services | ||||||
22 | ordered by a provider who qualifies for a service | ||||||
23 | authorization exemption, except in cases of fraud. | ||||||
24 | (f) This Section is repealed on December 31, 2030. | ||||||
25 | ARTICLE 155. |
| |||||||
| |||||||
1 | Section 155-5. The Community-Integrated Living | ||||||
2 | Arrangements Licensure and Certification Act is amended by | ||||||
3 | adding Section 13.3 as follows: | ||||||
4 | (210 ILCS 135/13.3 new) | ||||||
5 | Sec. 13.3. Community-integrated living arrangement per | ||||||
6 | diem reimbursement. As used in this Section, "medical absence" | ||||||
7 | means a situation in which a resident is temporarily absent | ||||||
8 | from a community-integrated living arrangement to receive | ||||||
9 | medical treatment or for other reasons that have been | ||||||
10 | recommended by third-party medical personnel, including, but | ||||||
11 | not limited to, hospitalizations, placements in short-term | ||||||
12 | stabilization homes or State-operated facilities, stays in | ||||||
13 | nursing facilities, rehabilitation in long-term care | ||||||
14 | facilities, or other absences for legitimate medical reasons. | ||||||
15 | Beginning January 1, 2025, the Department's Division of | ||||||
16 | Developmental Disabilities shall provide 100% of the per diem | ||||||
17 | reimbursement to a 24-hour community-integrated living | ||||||
18 | arrangement provider for up to 20 days for any resident | ||||||
19 | requiring a medical absence. During the medical absence, the | ||||||
20 | provider shall hold the bed for the resident. After the | ||||||
21 | medical absence, the resident shall return to the | ||||||
22 | community-integrated living arrangement when the resident is | ||||||
23 | medically able to return in order for the provider to receive | ||||||
24 | the full per diem reimbursement for the absent days. The per |
| |||||||
| |||||||
1 | diem reimbursement shall be in addition to the existing | ||||||
2 | occupancy factor policy set by the Division of Developmental | ||||||
3 | Disabilities. | ||||||
4 | ARTICLE 160. | ||||||
5 | Section 160-5. The Illinois Public Aid Code is amended by | ||||||
6 | adding Section 5-5.12f as follows: | ||||||
7 | (305 ILCS 5/5-5.12f new) | ||||||
8 | Sec. 5-5.12f. Prescription drugs for mental illness; no | ||||||
9 | utilization or prior approval mandates. | ||||||
10 | (a) Notwithstanding any other provision of this Code to | ||||||
11 | the contrary, except as otherwise provided in subsection (b), | ||||||
12 | for the purpose of removing barriers to the timely treatment | ||||||
13 | of serious mental illnesses, prior authorization mandates and | ||||||
14 | utilization management controls shall not be imposed under the | ||||||
15 | fee-for-service and managed care medical assistance programs | ||||||
16 | on any FDA-approved prescription drug that is recognized by a | ||||||
17 | generally accepted standard medical reference as effective in | ||||||
18 | the treatment of conditions specified in the most recent | ||||||
19 | Diagnostic and Statistical Manual of Mental Disorders | ||||||
20 | published by the American Psychiatric Association if a | ||||||
21 | preferred or non-preferred drug is prescribed to an adult | ||||||
22 | patient to treat serious mental illness and one of the | ||||||
23 | following applies: |
| |||||||
| |||||||
1 | (1) the patient has changed providers, including, but | ||||||
2 | not limited to, a change from an inpatient to an | ||||||
3 | outpatient provider, and is stable on the drug that has | ||||||
4 | been previously prescribed, and received prior | ||||||
5 | authorization, if required; | ||||||
6 | (2) the patient has changed insurance coverage and is | ||||||
7 | stable on the drug that has been previously prescribed and | ||||||
8 | received prior authorization under the previous source of | ||||||
9 | coverage; or | ||||||
10 | (3) subject to federal law on maximum dosage limits | ||||||
11 | and safety edits adopted by the Department's Drug and | ||||||
12 | Therapeutics Board, including those safety edits and | ||||||
13 | limits needed to comply with federal requirements | ||||||
14 | contained in 42 CFR 456.703, the patient has previously | ||||||
15 | been prescribed and obtained prior authorization for the | ||||||
16 | drug and the prescription modifies the dosage, dosage | ||||||
17 | frequency, or both, of the drug as part of the same | ||||||
18 | treatment for which the drug was previously prescribed. | ||||||
19 | (b) The following safety edits shall be permitted for | ||||||
20 | prescription drugs covered under this Section: | ||||||
21 | (1) clinically appropriate drug utilization review | ||||||
22 | (DUR) edits, including, but not limited to, drug-to-drug, | ||||||
23 | drug-age, and drug-dose; | ||||||
24 | (2) generic drug substitution if a generic drug is | ||||||
25 | available for the prescribed medication in the same dosage | ||||||
26 | and formulation; and |
| |||||||
| |||||||
1 | (3) any utilization management control that is | ||||||
2 | necessary for the Department to comply with any current | ||||||
3 | consent decrees or federal waivers. | ||||||
4 | (c) As used in this Section, "serious mental illness" | ||||||
5 | means any one or more of the following diagnoses and | ||||||
6 | International Classification of Diseases, Tenth Revision, | ||||||
7 | Clinical Modification (ICD-10-CM) codes listed by the | ||||||
8 | Department of Human Services' Division of Mental Health, as | ||||||
9 | amended, on its official website: | ||||||
10 | (1) Delusional Disorder (F22) | ||||||
11 | (2) Brief Psychotic Disorder (F23) | ||||||
12 | (3) Schizophreniform Disorder (F20.81) | ||||||
13 | (4) Schizophrenia (F20.9) | ||||||
14 | (5) Schizoaffective Disorder (F25.x) | ||||||
15 | (6) Catatonia Associated with Another Mental Disorder | ||||||
16 | (Catatonia Specifier) (F06.1) | ||||||
17 | (7) Other Specified Schizophrenia Spectrum and Other | ||||||
18 | Psychotic Disorder (F28) | ||||||
19 | (8) Unspecified Schizophrenia Spectrum and Other | ||||||
20 | Psychotic Disorder (F29) | ||||||
21 | (9) Bipolar I Disorder (F31.xx) | ||||||
22 | (10) Bipolar II Disorder (F31.81) | ||||||
23 | (11) Cyclothymic Disorder (F34.0) | ||||||
24 | (12) Unspecified Bipolar and Related Disorder (F31.9) | ||||||
25 | (13) Disruptive Mood Dysregulation Disorder (F34.8) | ||||||
26 | (14) Major Depressive Disorder Single episode (F32.xx) |
| |||||||
| |||||||
1 | (15) Major Depressive Disorder, Recurrent episode | ||||||
2 | (F33.xx) | ||||||
3 | (16) Obsessive-Compulsive Disorder (F42) | ||||||
4 | (17) Posttraumatic Stress Disorder (F43.10) | ||||||
5 | (18) Anorexia Nervosa (F50.0x) | ||||||
6 | (19) Bulimia Nervosa (F50.2) | ||||||
7 | (20) Postpartum Depression (F53.0) | ||||||
8 | (21) Puerperal Psychosis (F53.1) | ||||||
9 | (22) Factitious Disorder Imposed on Another (F68.A) | ||||||
10 | (d) Notwithstanding any other provision of law, nothing in | ||||||
11 | this Section shall not be construed to conflict with Section | ||||||
12 | 1927(a)(1) and (b)(1)(A) of the federal Social Security Act | ||||||
13 | and any implementing regulations and agreements. | ||||||
14 | ARTICLE 165. | ||||||
15 | Section 165-5. The Illinois Public Aid Code is amended by | ||||||
16 | changing Section 5-5.01a as follows: | ||||||
17 | (305 ILCS 5/5-5.01a) | ||||||
18 | Sec. 5-5.01a. Supportive living facilities program. | ||||||
19 | (a) The Department shall establish and provide oversight | ||||||
20 | for a program of supportive living facilities that seek to | ||||||
21 | promote resident independence, dignity, respect, and | ||||||
22 | well-being in the most cost-effective manner. | ||||||
23 | A supportive living facility is (i) a free-standing |
| |||||||
| |||||||
1 | facility or (ii) a distinct physical and operational entity | ||||||
2 | within a mixed-use building that meets the criteria | ||||||
3 | established in subsection (d). A supportive living facility | ||||||
4 | integrates housing with health, personal care, and supportive | ||||||
5 | services and is a designated setting that offers residents | ||||||
6 | their own separate, private, and distinct living units. | ||||||
7 | Sites for the operation of the program shall be selected | ||||||
8 | by the Department based upon criteria that may include the | ||||||
9 | need for services in a geographic area, the availability of | ||||||
10 | funding, and the site's ability to meet the standards. | ||||||
11 | (b) Beginning July 1, 2014, subject to federal approval, | ||||||
12 | the Medicaid rates for supportive living facilities shall be | ||||||
13 | equal to the supportive living facility Medicaid rate | ||||||
14 | effective on June 30, 2014 increased by 8.85%. Once the | ||||||
15 | assessment imposed at Article V-G of this Code is determined | ||||||
16 | to be a permissible tax under Title XIX of the Social Security | ||||||
17 | Act, the Department shall increase the Medicaid rates for | ||||||
18 | supportive living facilities effective on July 1, 2014 by | ||||||
19 | 9.09%. The Department shall apply this increase retroactively | ||||||
20 | to coincide with the imposition of the assessment in Article | ||||||
21 | V-G of this Code in accordance with the approval for federal | ||||||
22 | financial participation by the Centers for Medicare and | ||||||
23 | Medicaid Services. | ||||||
24 | The Medicaid rates for supportive living facilities | ||||||
25 | effective on July 1, 2017 must be equal to the rates in effect | ||||||
26 | for supportive living facilities on June 30, 2017 increased by |
| |||||||
| |||||||
1 | 2.8%. | ||||||
2 | The Medicaid rates for supportive living facilities | ||||||
3 | effective on July 1, 2018 must be equal to the rates in effect | ||||||
4 | for supportive living facilities on June 30, 2018. | ||||||
5 | Subject to federal approval, the Medicaid rates for | ||||||
6 | supportive living services on and after July 1, 2019 must be at | ||||||
7 | least 54.3% of the average total nursing facility services per | ||||||
8 | diem for the geographic areas defined by the Department while | ||||||
9 | maintaining the rate differential for dementia care and must | ||||||
10 | be updated whenever the total nursing facility service per | ||||||
11 | diems are updated. Beginning July 1, 2022, upon the | ||||||
12 | implementation of the Patient Driven Payment Model, Medicaid | ||||||
13 | rates for supportive living services must be at least 54.3% of | ||||||
14 | the average total nursing services per diem rate for the | ||||||
15 | geographic areas. For purposes of this provision, the average | ||||||
16 | total nursing services per diem rate shall include all add-ons | ||||||
17 | for nursing facilities for the geographic area provided for in | ||||||
18 | Section 5-5.2. The rate differential for dementia care must be | ||||||
19 | maintained in these rates and the rates shall be updated | ||||||
20 | whenever nursing facility per diem rates are updated. | ||||||
21 | Subject to federal approval, beginning January 1, 2024, | ||||||
22 | the dementia care rate for supportive living services must be | ||||||
23 | no less than the non-dementia care supportive living services | ||||||
24 | rate multiplied by 1.5. | ||||||
25 | (c) The Department may adopt rules to implement this | ||||||
26 | Section. Rules that establish or modify the services, |
| |||||||
| |||||||
1 | standards, and conditions for participation in the program | ||||||
2 | shall be adopted by the Department in consultation with the | ||||||
3 | Department on Aging, the Department of Rehabilitation | ||||||
4 | Services, and the Department of Mental Health and | ||||||
5 | Developmental Disabilities (or their successor agencies). | ||||||
6 | (d) Subject to federal approval by the Centers for | ||||||
7 | Medicare and Medicaid Services, the Department shall accept | ||||||
8 | for consideration of certification under the program any | ||||||
9 | application for a site or building where distinct parts of the | ||||||
10 | site or building are designated for purposes other than the | ||||||
11 | provision of supportive living services, but only if: | ||||||
12 | (1) those distinct parts of the site or building are | ||||||
13 | not designated for the purpose of providing assisted | ||||||
14 | living services as required under the Assisted Living and | ||||||
15 | Shared Housing Act; | ||||||
16 | (2) those distinct parts of the site or building are | ||||||
17 | completely separate from the part of the building used for | ||||||
18 | the provision of supportive living program services, | ||||||
19 | including separate entrances; | ||||||
20 | (3) those distinct parts of the site or building do | ||||||
21 | not share any common spaces with the part of the building | ||||||
22 | used for the provision of supportive living program | ||||||
23 | services; and | ||||||
24 | (4) those distinct parts of the site or building do | ||||||
25 | not share staffing with the part of the building used for | ||||||
26 | the provision of supportive living program services. |
| |||||||
| |||||||
1 | (e) Facilities or distinct parts of facilities which are | ||||||
2 | selected as supportive living facilities and are in good | ||||||
3 | standing with the Department's rules are exempt from the | ||||||
4 | provisions of the Nursing Home Care Act and the Illinois | ||||||
5 | Health Facilities Planning Act. | ||||||
6 | (f) Section 9817 of the American Rescue Plan Act of 2021 | ||||||
7 | (Public Law 117-2) authorizes a 10% enhanced federal medical | ||||||
8 | assistance percentage for supportive living services for a | ||||||
9 | 12-month period from April 1, 2021 through March 31, 2022. | ||||||
10 | Subject to federal approval, including the approval of any | ||||||
11 | necessary waiver amendments or other federally required | ||||||
12 | documents or assurances, for a 12-month period the Department | ||||||
13 | must pay a supplemental $26 per diem rate to all supportive | ||||||
14 | living facilities with the additional federal financial | ||||||
15 | participation funds that result from the enhanced federal | ||||||
16 | medical assistance percentage from April 1, 2021 through March | ||||||
17 | 31, 2022. The Department may issue parameters around how the | ||||||
18 | supplemental payment should be spent, including quality | ||||||
19 | improvement activities. The Department may alter the form, | ||||||
20 | methods, or timeframes concerning the supplemental per diem | ||||||
21 | rate to comply with any subsequent changes to federal law, | ||||||
22 | changes made by guidance issued by the federal Centers for | ||||||
23 | Medicare and Medicaid Services, or other changes necessary to | ||||||
24 | receive the enhanced federal medical assistance percentage. | ||||||
25 | (g) All applications for the expansion of supportive | ||||||
26 | living dementia care settings involving sites not approved by |
| |||||||
| |||||||
1 | the Department on January 1, 2024 ( the effective date of | ||||||
2 | Public Act 103-102) this amendatory Act of the 103rd General | ||||||
3 | Assembly may allow new elderly non-dementia units in addition | ||||||
4 | to new dementia care units. The Department may approve such | ||||||
5 | applications only if the application has: (1) no more than one | ||||||
6 | non-dementia care unit for each dementia care unit and (2) the | ||||||
7 | site is not located within 4 miles of an existing supportive | ||||||
8 | living program site in Cook County (including the City of | ||||||
9 | Chicago), not located within 12 miles of an existing | ||||||
10 | supportive living program site in DuPage County, Kane County, | ||||||
11 | Lake County, McHenry County, or Will County, or not located | ||||||
12 | within 25 miles of an existing supportive living program site | ||||||
13 | in any other county. | ||||||
14 | (h) As stated in the supportive living program home and | ||||||
15 | community-based service waiver approved by the federal Centers | ||||||
16 | for Medicare and Medicaid Services, and beginning July 1, | ||||||
17 | 2025, the Department must maintain the rate add-on implemented | ||||||
18 | on January 1, 2023 for the provision of 2 meals per day at no | ||||||
19 | less than $6.15 per day. | ||||||
20 | (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; | ||||||
21 | 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, | ||||||
22 | Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.) | ||||||
23 | ARTICLE 170. | ||||||
24 | Section 170-5. The Illinois Public Aid Code is amended by |
| |||||||
| |||||||
1 | adding Section 5-2.06a as follows: | ||||||
2 | (305 ILCS 5/5-2.06a new) | ||||||
3 | Sec. 5-2.06a. Medically fragile children; reimbursement | ||||||
4 | for legally responsible family caregivers. By January 1, 2025, | ||||||
5 | the Department of Healthcare and Family Services shall apply | ||||||
6 | for a Home and Community-Based Services State Plan amendment | ||||||
7 | and any federal waiver necessary to reimburse legally | ||||||
8 | responsible family caregivers as providers of personal care or | ||||||
9 | home health aide services under the Illinois Title XIX State | ||||||
10 | Plan Home and Community-Based Services benefit and the home | ||||||
11 | and community-based services waiver program authorized under | ||||||
12 | Section 1915(c) of the Social Security Act for persons who are | ||||||
13 | medically fragile and technology dependent. To be eligible for | ||||||
14 | reimbursement under this Section, a legally responsible family | ||||||
15 | caregiver must be a certified nursing assistant or certified | ||||||
16 | nurse aide and must provide services to a medically fragile | ||||||
17 | relative who is receiving in-home shift nursing services | ||||||
18 | coordinated by the University of Illinois at Chicago, Division | ||||||
19 | of Specialized Care for Children. Upon federal approval of the | ||||||
20 | State Plan amendment and waiver, the Department shall | ||||||
21 | promulgate rules that define who qualifies for reimbursement | ||||||
22 | as a legally responsible family caregiver, specify which | ||||||
23 | personal care and home health aide services are eligible for | ||||||
24 | reimbursement if the provider is a legally responsible family | ||||||
25 | caregiver, establish oversight policies to ensure legally |
| |||||||
| |||||||
1 | responsible family caregivers meet and comply with licensing | ||||||
2 | and program requirements, and adopt any other policies or | ||||||
3 | procedures necessary to implement this Section. | ||||||
4 | ARTICLE 175. | ||||||
5 | Section 175-5. The Illinois Public Aid Code is amended by | ||||||
6 | changing Section 5-5.5 as follows: | ||||||
7 | (305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5) | ||||||
8 | Sec. 5-5.5. Elements of Payment Rate. | ||||||
9 | (a) The Department of Healthcare and Family Services shall | ||||||
10 | develop a prospective method for determining payment rates for | ||||||
11 | nursing facility and ICF/DD services in nursing facilities | ||||||
12 | composed of the following cost elements: | ||||||
13 | (1) Standard Services, with the cost of this component | ||||||
14 | being determined by taking into account the actual costs | ||||||
15 | to the facilities of these services subject to cost | ||||||
16 | ceilings to be defined in the Department's rules. | ||||||
17 | (2) Resident Services, with the cost of this component | ||||||
18 | being determined by taking into account the actual costs, | ||||||
19 | needs and utilization of these services, as derived from | ||||||
20 | an assessment of the resident needs in the nursing | ||||||
21 | facilities. | ||||||
22 | (3) Ancillary Services, with the payment rate being | ||||||
23 | developed for each individual type of service. Payment |
| |||||||
| |||||||
1 | shall be made only when authorized under procedures | ||||||
2 | developed by the Department of Healthcare and Family | ||||||
3 | Services. | ||||||
4 | (4) Nurse's Aide Training, with the cost of this | ||||||
5 | component being determined by taking into account the | ||||||
6 | actual cost to the facilities of such training. | ||||||
7 | (5) Real Estate Taxes, with the cost of this component | ||||||
8 | being determined by taking into account the figures | ||||||
9 | contained in the most currently available cost reports | ||||||
10 | (with no imposition of maximums) updated to the midpoint | ||||||
11 | of the current rate year for long term care services | ||||||
12 | rendered between July 1, 1984 and June 30, 1985, and with | ||||||
13 | the cost of this component being determined by taking into | ||||||
14 | account the actual 1983 taxes for which the nursing homes | ||||||
15 | were assessed (with no imposition of maximums) updated to | ||||||
16 | the midpoint of the current rate year for long term care | ||||||
17 | services rendered between July 1, 1985 and June 30, 1986. | ||||||
18 | (b) In developing a prospective method for determining | ||||||
19 | payment rates for nursing facility and ICF/DD services in | ||||||
20 | nursing facilities and ICF/DDs, the Department of Healthcare | ||||||
21 | and Family Services shall consider the following cost | ||||||
22 | elements: | ||||||
23 | (1) Reasonable capital cost determined by utilizing | ||||||
24 | incurred interest rate and the current value of the | ||||||
25 | investment, including land, utilizing composite rates, or | ||||||
26 | by utilizing such other reasonable cost related methods |
| |||||||
| |||||||
1 | determined by the Department. However, beginning with the | ||||||
2 | rate reimbursement period effective July 1, 1987, the | ||||||
3 | Department shall be prohibited from establishing, | ||||||
4 | including, and implementing any depreciation factor in | ||||||
5 | calculating the capital cost element. | ||||||
6 | (2) Profit, with the actual amount being produced and | ||||||
7 | accruing to the providers in the form of a return on their | ||||||
8 | total investment, on the basis of their ability to | ||||||
9 | economically and efficiently deliver a type of service. | ||||||
10 | The method of payment may assure the opportunity for a | ||||||
11 | profit, but shall not guarantee or establish a specific | ||||||
12 | amount as a cost. | ||||||
13 | (c) The Illinois Department may implement the amendatory | ||||||
14 | changes to this Section made by this amendatory Act of 1991 | ||||||
15 | through the use of emergency rules in accordance with the | ||||||
16 | provisions of Section 5.02 of the Illinois Administrative | ||||||
17 | Procedure Act. For purposes of the Illinois Administrative | ||||||
18 | Procedure Act, the adoption of rules to implement the | ||||||
19 | amendatory changes to this Section made by this amendatory Act | ||||||
20 | of 1991 shall be deemed an emergency and necessary for the | ||||||
21 | public interest, safety and welfare. | ||||||
22 | (d) No later than January 1, 2001, the Department of | ||||||
23 | Public Aid shall file with the Joint Committee on | ||||||
24 | Administrative Rules, pursuant to the Illinois Administrative | ||||||
25 | Procedure Act, a proposed rule, or a proposed amendment to an | ||||||
26 | existing rule, regarding payment for appropriate services, |
| |||||||
| |||||||
1 | including assessment, care planning, discharge planning, and | ||||||
2 | treatment provided by nursing facilities to residents who have | ||||||
3 | a serious mental illness. | ||||||
4 | (e) On and after July 1, 2012, the Department shall reduce | ||||||
5 | any rate of reimbursement for services or other payments or | ||||||
6 | alter any methodologies authorized by this Code to reduce any | ||||||
7 | rate of reimbursement for services or other payments in | ||||||
8 | accordance with Section 5-5e. | ||||||
9 | (f) Beginning January 1, 2025, the real estate tax | ||||||
10 | component of the payment rate shall be updated using the most | ||||||
11 | recent property tax bill on file with the Department for | ||||||
12 | facilities licensed under the Nursing Home Care Act and | ||||||
13 | facilities licensed under the Specialized Mental Health | ||||||
14 | Rehabilitation Act of 2013. The per diem rate shall be | ||||||
15 | computed by dividing the real estate tax costs reported in the | ||||||
16 | cost report inflated to the midpoint of the rate year by the | ||||||
17 | total number of patient days reported in the same cost report. | ||||||
18 | Computation of the real estate tax component shall be based on | ||||||
19 | capital days. | ||||||
20 | (Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11; | ||||||
21 | 97-689, eff. 6-14-12.) | ||||||
22 | ARTICLE 180. | ||||||
23 | Section 180-5. The Illinois Public Aid Code is amended by | ||||||
24 | changing Section 5-5.2 as follows: |
| |||||||
| |||||||
1 | (305 ILCS 5/5-5.2) | ||||||
2 | Sec. 5-5.2. Payment. | ||||||
3 | (a) All nursing facilities that are grouped pursuant to | ||||||
4 | Section 5-5.1 of this Act shall receive the same rate of | ||||||
5 | payment for similar services. | ||||||
6 | (b) It shall be a matter of State policy that the Illinois | ||||||
7 | Department shall utilize a uniform billing cycle throughout | ||||||
8 | the State for the long-term care providers. | ||||||
9 | (c) (Blank). | ||||||
10 | (c-1) Notwithstanding any other provisions of this Code, | ||||||
11 | the methodologies for reimbursement of nursing services as | ||||||
12 | provided under this Article shall no longer be applicable for | ||||||
13 | bills payable for nursing services rendered on or after a new | ||||||
14 | reimbursement system based on the Patient Driven Payment Model | ||||||
15 | (PDPM) has been fully operationalized, which shall take effect | ||||||
16 | for services provided on or after the implementation of the | ||||||
17 | PDPM reimbursement system begins. For the purposes of Public | ||||||
18 | Act 102-1035 this amendatory Act of the 102nd General | ||||||
19 | Assembly , the implementation date of the PDPM reimbursement | ||||||
20 | system and all related provisions shall be July 1, 2022 if the | ||||||
21 | following conditions are met: (i) the Centers for Medicare and | ||||||
22 | Medicaid Services has approved corresponding changes in the | ||||||
23 | reimbursement system and bed assessment; and (ii) the | ||||||
24 | Department has filed rules to implement these changes no later | ||||||
25 | than June 1, 2022. Failure of the Department to file rules to |
| |||||||
| |||||||
1 | implement the changes provided in Public Act 102-1035 this | ||||||
2 | amendatory Act of the 102nd General Assembly no later than | ||||||
3 | June 1, 2022 shall result in the implementation date being | ||||||
4 | delayed to October 1, 2022. | ||||||
5 | (d) The new nursing services reimbursement methodology | ||||||
6 | utilizing the Patient Driven Payment Model, which shall be | ||||||
7 | referred to as the PDPM reimbursement system, taking effect | ||||||
8 | July 1, 2022, upon federal approval by the Centers for | ||||||
9 | Medicare and Medicaid Services, shall be based on the | ||||||
10 | following: | ||||||
11 | (1) The methodology shall be resident-centered, | ||||||
12 | facility-specific, cost-based, and based on guidance from | ||||||
13 | the Centers for Medicare and Medicaid Services. | ||||||
14 | (2) Costs shall be annually rebased and case mix index | ||||||
15 | quarterly updated. The nursing services methodology will | ||||||
16 | be assigned to the Medicaid enrolled residents on record | ||||||
17 | as of 30 days prior to the beginning of the rate period in | ||||||
18 | the Department's Medicaid Management Information System | ||||||
19 | (MMIS) as present on the last day of the second quarter | ||||||
20 | preceding the rate period based upon the Assessment | ||||||
21 | Reference Date of the Minimum Data Set (MDS). | ||||||
22 | (3) Regional wage adjustors based on the Health | ||||||
23 | Service Areas (HSA) groupings and adjusters in effect on | ||||||
24 | April 30, 2012 shall be included, except no adjuster shall | ||||||
25 | be lower than 1.06. | ||||||
26 | (4) PDPM nursing case mix indices in effect on March |
| |||||||
| |||||||
1 | 1, 2022 shall be assigned to each resident class at no less | ||||||
2 | than 0.7858 of the Centers for Medicare and Medicaid | ||||||
3 | Services PDPM unadjusted case mix values, in effect on | ||||||
4 | March 1, 2022. | ||||||
5 | (5) The pool of funds available for distribution by | ||||||
6 | case mix and the base facility rate shall be determined | ||||||
7 | using the formula contained in subsection (d-1). | ||||||
8 | (6) The Department shall establish a variable per diem | ||||||
9 | staffing add-on in accordance with the most recent | ||||||
10 | available federal staffing report, currently the Payroll | ||||||
11 | Based Journal, for the same period of time, and if | ||||||
12 | applicable adjusted for acuity using the same quarter's | ||||||
13 | MDS. The Department shall rely on Payroll Based Journals | ||||||
14 | provided to the Department of Public Health to make a | ||||||
15 | determination of non-submission. If the Department is | ||||||
16 | notified by a facility of missing or inaccurate Payroll | ||||||
17 | Based Journal data or an incorrect calculation of | ||||||
18 | staffing, the Department must make a correction as soon as | ||||||
19 | the error is verified for the applicable quarter. | ||||||
20 | Beginning October 1, 2024, the staffing percentage | ||||||
21 | used in the calculation of the per diem staffing add-on | ||||||
22 | shall be its PDPM STRIVE Staffing Ratio which equals: its | ||||||
23 | Reported Total Nurse Staffing Hours Per Resident Per Day | ||||||
24 | as published in the most recent federal staffing report | ||||||
25 | (the Provider Information File), divided by the facility's | ||||||
26 | PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE |
| |||||||
| |||||||
1 | Staffing Target is equal to .82 times the facility's | ||||||
2 | Illinois Adjusted Facility Case-Mix Hours Per Resident Per | ||||||
3 | Day. A facility's Illinois Adjusted Facility Case Mix | ||||||
4 | Hours Per Resident Per Day is equal to its Case-Mix Total | ||||||
5 | Nurse Staffing Hours Per Resident Per Day (as published in | ||||||
6 | the most recent federal staffing report) times 3.662 | ||||||
7 | (which reflects the national resident days-weighted mean | ||||||
8 | Reported Total Nurse Staffing Hours Per Resident Per Day | ||||||
9 | as calculated using the January 2024 federal Provider | ||||||
10 | Information Files), divided by the national resident | ||||||
11 | days-weighted mean Reported Total Nurse Staffing Hours Per | ||||||
12 | Resident Per Day calculated using the most recent federal | ||||||
13 | Provider Information File. | ||||||
14 | (6.5) Beginning July 1, 2024, the paid per diem | ||||||
15 | staffing add-on shall be the paid per diem staffing add-on | ||||||
16 | in effect April 1, 2024. For dates beginning October 1, | ||||||
17 | 2024 and through September 30, 2025, the denominator for | ||||||
18 | the staffing percentage shall be the lesser of the | ||||||
19 | facility's PDPM STRIVE Staffing Target and: | ||||||
20 | (A) For the quarter beginning October 1, 2024, the | ||||||
21 | sum of 20% of the facility's PDPM STRIVE Staffing | ||||||
22 | Target and 80% of the facility's Case-Mix Total Nurse | ||||||
23 | Staffing Hours Per Resident Per Day (as published in | ||||||
24 | the January 2024 federal staffing report). | ||||||
25 | (B) For the quarter beginning January 1, 2025, the | ||||||
26 | sum of 40% of the facility's PDPM STRIVE Staffing |
| |||||||
| |||||||
1 | Target and 60% of the facility's Case-Mix Total Nurse | ||||||
2 | Staffing Hours Per Resident Per Day (as published in | ||||||
3 | the January 2024 federal staffing report). | ||||||
4 | (C) For the quarter beginning March 1, 2025, the | ||||||
5 | sum of 60% of the facility's PDPM STRIVE Staffing | ||||||
6 | Target and 40% of the facility's Case-Mix Total Nurse | ||||||
7 | Staffing Hours Per Resident Per Day (as published in | ||||||
8 | the January 2024 federal staffing report). | ||||||
9 | (D) For the quarter beginning July 1, 2025, the | ||||||
10 | sum of 80% of the facility's PDPM STRIVE Staffing | ||||||
11 | Target and 20% of the facility's Case-Mix Total Nurse | ||||||
12 | Staffing Hours Per Resident Per Day (as published in | ||||||
13 | the January 2024 federal staffing report). | ||||||
14 | Facilities with at least 70% of the staffing | ||||||
15 | indicated by the STRIVE study shall be paid a per diem | ||||||
16 | add-on of $9, increasing by equivalent steps for each | ||||||
17 | whole percentage point until the facilities reach a per | ||||||
18 | diem of $16.52 $14.88 . Facilities with at least 80% of the | ||||||
19 | staffing indicated by the STRIVE study shall be paid a per | ||||||
20 | diem add-on of $16.52 $14.88 , increasing by equivalent | ||||||
21 | steps for each whole percentage point until the facilities | ||||||
22 | reach a per diem add-on of $25.77 $23.80 . Facilities with | ||||||
23 | at least 92% of the staffing indicated by the STRIVE study | ||||||
24 | shall be paid a per diem add-on of $25.77 $23.80 , | ||||||
25 | increasing by equivalent steps for each whole percentage | ||||||
26 | point until the facilities reach a per diem add-on of |
| |||||||
| |||||||
1 | $30.98 $29.75 . Facilities with at least 100% of the | ||||||
2 | staffing indicated by the STRIVE study shall be paid a per | ||||||
3 | diem add-on of $30.98 $29.75 , increasing by equivalent | ||||||
4 | steps for each whole percentage point until the facilities | ||||||
5 | reach a per diem add-on of $36.44 $35.70 . Facilities with | ||||||
6 | at least 110% of the staffing indicated by the STRIVE | ||||||
7 | study shall be paid a per diem add-on of $36.44 $35.70 , | ||||||
8 | increasing by equivalent steps for each whole percentage | ||||||
9 | point until the facilities reach a per diem add-on of | ||||||
10 | $38.68. Facilities with at least 125% or higher of the | ||||||
11 | staffing indicated by the STRIVE study shall be paid a per | ||||||
12 | diem add-on of $38.68. No Beginning April 1, 2023, no | ||||||
13 | nursing facility's variable staffing per diem add-on shall | ||||||
14 | be reduced by more than 5% in 2 consecutive quarters. For | ||||||
15 | the quarters beginning July 1, 2022 and October 1, 2022, | ||||||
16 | no facility's variable per diem staffing add-on shall be | ||||||
17 | calculated at a rate lower than 85% of the staffing | ||||||
18 | indicated by the STRIVE study. No facility below 70% of | ||||||
19 | the staffing indicated by the STRIVE study shall receive a | ||||||
20 | variable per diem staffing add-on after December 31, 2022. | ||||||
21 | (7) For dates of services beginning July 1, 2022, the | ||||||
22 | PDPM nursing component per diem for each nursing facility | ||||||
23 | shall be the product of the facility's (i) statewide PDPM | ||||||
24 | nursing base per diem rate, $92.25, adjusted for the | ||||||
25 | facility average PDPM case mix index calculated quarterly | ||||||
26 | and (ii) the regional wage adjuster, and then add the |
| |||||||
| |||||||
1 | Medicaid access adjustment as defined in (e-3) of this | ||||||
2 | Section. Transition rates for services provided between | ||||||
3 | July 1, 2022 and October 1, 2023 shall be the greater of | ||||||
4 | the PDPM nursing component per diem or: | ||||||
5 | (A) for the quarter beginning July 1, 2022, the | ||||||
6 | RUG-IV nursing component per diem; | ||||||
7 | (B) for the quarter beginning October 1, 2022, the | ||||||
8 | sum of the RUG-IV nursing component per diem | ||||||
9 | multiplied by 0.80 and the PDPM nursing component per | ||||||
10 | diem multiplied by 0.20; | ||||||
11 | (C) for the quarter beginning January 1, 2023, the | ||||||
12 | sum of the RUG-IV nursing component per diem | ||||||
13 | multiplied by 0.60 and the PDPM nursing component per | ||||||
14 | diem multiplied by 0.40; | ||||||
15 | (D) for the quarter beginning April 1, 2023, the | ||||||
16 | sum of the RUG-IV nursing component per diem | ||||||
17 | multiplied by 0.40 and the PDPM nursing component per | ||||||
18 | diem multiplied by 0.60; | ||||||
19 | (E) for the quarter beginning July 1, 2023, the | ||||||
20 | sum of the RUG-IV nursing component per diem | ||||||
21 | multiplied by 0.20 and the PDPM nursing component per | ||||||
22 | diem multiplied by 0.80; or | ||||||
23 | (F) for the quarter beginning October 1, 2023 and | ||||||
24 | each subsequent quarter, the transition rate shall end | ||||||
25 | and a nursing facility shall be paid 100% of the PDPM | ||||||
26 | nursing component per diem. |
| |||||||
| |||||||
1 | (d-1) Calculation of base year Statewide RUG-IV nursing | ||||||
2 | base per diem rate. | ||||||
3 | (1) Base rate spending pool shall be: | ||||||
4 | (A) The base year resident days which are | ||||||
5 | calculated by multiplying the number of Medicaid | ||||||
6 | residents in each nursing home as indicated in the MDS | ||||||
7 | data defined in paragraph (4) by 365. | ||||||
8 | (B) Each facility's nursing component per diem in | ||||||
9 | effect on July 1, 2012 shall be multiplied by | ||||||
10 | subsection (A). | ||||||
11 | (C) Thirteen million is added to the product of | ||||||
12 | subparagraph (A) and subparagraph (B) to adjust for | ||||||
13 | the exclusion of nursing homes defined in paragraph | ||||||
14 | (5). | ||||||
15 | (2) For each nursing home with Medicaid residents as | ||||||
16 | indicated by the MDS data defined in paragraph (4), | ||||||
17 | weighted days adjusted for case mix and regional wage | ||||||
18 | adjustment shall be calculated. For each home this | ||||||
19 | calculation is the product of: | ||||||
20 | (A) Base year resident days as calculated in | ||||||
21 | subparagraph (A) of paragraph (1). | ||||||
22 | (B) The nursing home's regional wage adjustor | ||||||
23 | based on the Health Service Areas (HSA) groupings and | ||||||
24 | adjustors in effect on April 30, 2012. | ||||||
25 | (C) Facility weighted case mix which is the number | ||||||
26 | of Medicaid residents as indicated by the MDS data |
| |||||||
| |||||||
1 | defined in paragraph (4) multiplied by the associated | ||||||
2 | case weight for the RUG-IV 48 grouper model using | ||||||
3 | standard RUG-IV procedures for index maximization. | ||||||
4 | (D) The sum of the products calculated for each | ||||||
5 | nursing home in subparagraphs (A) through (C) above | ||||||
6 | shall be the base year case mix, rate adjusted | ||||||
7 | weighted days. | ||||||
8 | (3) The Statewide RUG-IV nursing base per diem rate: | ||||||
9 | (A) on January 1, 2014 shall be the quotient of the | ||||||
10 | paragraph (1) divided by the sum calculated under | ||||||
11 | subparagraph (D) of paragraph (2); | ||||||
12 | (B) on and after July 1, 2014 and until July 1, | ||||||
13 | 2022, shall be the amount calculated under | ||||||
14 | subparagraph (A) of this paragraph (3) plus $1.76; and | ||||||
15 | (C) beginning July 1, 2022 and thereafter, $7 | ||||||
16 | shall be added to the amount calculated under | ||||||
17 | subparagraph (B) of this paragraph (3) of this | ||||||
18 | Section. | ||||||
19 | (4) Minimum Data Set (MDS) comprehensive assessments | ||||||
20 | for Medicaid residents on the last day of the quarter used | ||||||
21 | to establish the base rate. | ||||||
22 | (5) Nursing facilities designated as of July 1, 2012 | ||||||
23 | by the Department as "Institutions for Mental Disease" | ||||||
24 | shall be excluded from all calculations under this | ||||||
25 | subsection. The data from these facilities shall not be | ||||||
26 | used in the computations described in paragraphs (1) |
| |||||||
| |||||||
1 | through (4) above to establish the base rate. | ||||||
2 | (e) Beginning July 1, 2014, the Department shall allocate | ||||||
3 | funding in the amount up to $10,000,000 for per diem add-ons to | ||||||
4 | the RUGS methodology for dates of service on and after July 1, | ||||||
5 | 2014: | ||||||
6 | (1) $0.63 for each resident who scores in I4200 | ||||||
7 | Alzheimer's Disease or I4800 non-Alzheimer's Dementia. | ||||||
8 | (2) $2.67 for each resident who scores either a "1" or | ||||||
9 | "2" in any items S1200A through S1200I and also scores in | ||||||
10 | RUG groups PA1, PA2, BA1, or BA2. | ||||||
11 | (e-1) (Blank). | ||||||
12 | (e-2) For dates of services beginning January 1, 2014 and | ||||||
13 | ending September 30, 2023, the RUG-IV nursing component per | ||||||
14 | diem for a nursing home shall be the product of the statewide | ||||||
15 | RUG-IV nursing base per diem rate, the facility average case | ||||||
16 | mix index, and the regional wage adjustor. For dates of | ||||||
17 | service beginning July 1, 2022 and ending September 30, 2023, | ||||||
18 | the Medicaid access adjustment described in subsection (e-3) | ||||||
19 | shall be added to the product. | ||||||
20 | (e-3) A Medicaid Access Adjustment of $4 adjusted for the | ||||||
21 | facility average PDPM case mix index calculated quarterly | ||||||
22 | shall be added to the statewide PDPM nursing per diem for all | ||||||
23 | facilities with annual Medicaid bed days of at least 70% of all | ||||||
24 | occupied bed days adjusted quarterly. For each new calendar | ||||||
25 | year and for the 6-month period beginning July 1, 2022, the | ||||||
26 | percentage of a facility's occupied bed days comprised of |
| |||||||
| |||||||
1 | Medicaid bed days shall be determined by the Department | ||||||
2 | quarterly. For dates of service beginning January 1, 2023, the | ||||||
3 | Medicaid Access Adjustment shall be increased to $4.75. This | ||||||
4 | subsection shall be inoperative on and after January 1, 2028. | ||||||
5 | (e-4) Subject to federal approval, on and after January 1, | ||||||
6 | 2024, the Department shall increase the rate add-on at | ||||||
7 | paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335 | ||||||
8 | for ventilator services from $208 per day to $481 per day. | ||||||
9 | Payment is subject to the criteria and requirements under 89 | ||||||
10 | Ill. Adm. Code 147.335. | ||||||
11 | (f) (Blank). | ||||||
12 | (g) Notwithstanding any other provision of this Code, on | ||||||
13 | and after July 1, 2012, for facilities not designated by the | ||||||
14 | Department of Healthcare and Family Services as "Institutions | ||||||
15 | for Mental Disease", rates effective May 1, 2011 shall be | ||||||
16 | adjusted as follows: | ||||||
17 | (1) (Blank); | ||||||
18 | (2) (Blank); | ||||||
19 | (3) Facility rates for the capital and support | ||||||
20 | components shall be reduced by 1.7%. | ||||||
21 | (h) Notwithstanding any other provision of this Code, on | ||||||
22 | and after July 1, 2012, nursing facilities designated by the | ||||||
23 | Department of Healthcare and Family Services as "Institutions | ||||||
24 | for Mental Disease" and "Institutions for Mental Disease" that | ||||||
25 | are facilities licensed under the Specialized Mental Health | ||||||
26 | Rehabilitation Act of 2013 shall have the nursing, |
| |||||||
| |||||||
1 | socio-developmental, capital, and support components of their | ||||||
2 | reimbursement rate effective May 1, 2011 reduced in total by | ||||||
3 | 2.7%. | ||||||
4 | (i) On and after July 1, 2014, the reimbursement rates for | ||||||
5 | the support component of the nursing facility rate for | ||||||
6 | facilities licensed under the Nursing Home Care Act as skilled | ||||||
7 | or intermediate care facilities shall be the rate in effect on | ||||||
8 | June 30, 2014 increased by 8.17%. | ||||||
9 | (i-1) Subject to federal approval, on and after January 1, | ||||||
10 | 2024, the reimbursement rates for the support component of the | ||||||
11 | nursing facility rate for facilities licensed under the | ||||||
12 | Nursing Home Care Act as skilled or intermediate care | ||||||
13 | facilities shall be the rate in effect on June 30, 2023 | ||||||
14 | increased by 12%. | ||||||
15 | (j) Notwithstanding any other provision of law, subject to | ||||||
16 | federal approval, effective July 1, 2019, sufficient funds | ||||||
17 | shall be allocated for changes to rates for facilities | ||||||
18 | licensed under the Nursing Home Care Act as skilled nursing | ||||||
19 | facilities or intermediate care facilities for dates of | ||||||
20 | services on and after July 1, 2019: (i) to establish, through | ||||||
21 | June 30, 2022 a per diem add-on to the direct care per diem | ||||||
22 | rate not to exceed $70,000,000 annually in the aggregate | ||||||
23 | taking into account federal matching funds for the purpose of | ||||||
24 | addressing the facility's unique staffing needs, adjusted | ||||||
25 | quarterly and distributed by a weighted formula based on | ||||||
26 | Medicaid bed days on the last day of the second quarter |
| |||||||
| |||||||
1 | preceding the quarter for which the rate is being adjusted. | ||||||
2 | Beginning July 1, 2022, the annual $70,000,000 described in | ||||||
3 | the preceding sentence shall be dedicated to the variable per | ||||||
4 | diem add-on for staffing under paragraph (6) of subsection | ||||||
5 | (d); and (ii) in an amount not to exceed $170,000,000 annually | ||||||
6 | in the aggregate taking into account federal matching funds to | ||||||
7 | permit the support component of the nursing facility rate to | ||||||
8 | be updated as follows: | ||||||
9 | (1) 80%, or $136,000,000, of the funds shall be used | ||||||
10 | to update each facility's rate in effect on June 30, 2019 | ||||||
11 | using the most recent cost reports on file, which have had | ||||||
12 | a limited review conducted by the Department of Healthcare | ||||||
13 | and Family Services and will not hold up enacting the rate | ||||||
14 | increase, with the Department of Healthcare and Family | ||||||
15 | Services. | ||||||
16 | (2) After completing the calculation in paragraph (1), | ||||||
17 | any facility whose rate is less than the rate in effect on | ||||||
18 | June 30, 2019 shall have its rate restored to the rate in | ||||||
19 | effect on June 30, 2019 from the 20% of the funds set | ||||||
20 | aside. | ||||||
21 | (3) The remainder of the 20%, or $34,000,000, shall be | ||||||
22 | used to increase each facility's rate by an equal | ||||||
23 | percentage. | ||||||
24 | (k) During the first quarter of State Fiscal Year 2020, | ||||||
25 | the Department of Healthcare of Family Services must convene a | ||||||
26 | technical advisory group consisting of members of all trade |
| |||||||
| |||||||
1 | associations representing Illinois skilled nursing providers | ||||||
2 | to discuss changes necessary with federal implementation of | ||||||
3 | Medicare's Patient-Driven Payment Model. Implementation of | ||||||
4 | Medicare's Patient-Driven Payment Model shall, by September 1, | ||||||
5 | 2020, end the collection of the MDS data that is necessary to | ||||||
6 | maintain the current RUG-IV Medicaid payment methodology. The | ||||||
7 | technical advisory group must consider a revised reimbursement | ||||||
8 | methodology that takes into account transparency, | ||||||
9 | accountability, actual staffing as reported under the | ||||||
10 | federally required Payroll Based Journal system, changes to | ||||||
11 | the minimum wage, adequacy in coverage of the cost of care, and | ||||||
12 | a quality component that rewards quality improvements. | ||||||
13 | (l) The Department shall establish per diem add-on | ||||||
14 | payments to improve the quality of care delivered by | ||||||
15 | facilities, including: | ||||||
16 | (1) Incentive payments determined by facility | ||||||
17 | performance on specified quality measures in an initial | ||||||
18 | amount of $70,000,000. Nothing in this subsection shall be | ||||||
19 | construed to limit the quality of care payments in the | ||||||
20 | aggregate statewide to $70,000,000, and, if quality of | ||||||
21 | care has improved across nursing facilities, the | ||||||
22 | Department shall adjust those add-on payments accordingly. | ||||||
23 | The quality payment methodology described in this | ||||||
24 | subsection must be used for at least State Fiscal Year | ||||||
25 | 2023. Beginning with the quarter starting July 1, 2023, | ||||||
26 | the Department may add, remove, or change quality metrics |
| |||||||
| |||||||
1 | and make associated changes to the quality payment | ||||||
2 | methodology as outlined in subparagraph (E). Facilities | ||||||
3 | designated by the Centers for Medicare and Medicaid | ||||||
4 | Services as a special focus facility or a hospital-based | ||||||
5 | nursing home do not qualify for quality payments. | ||||||
6 | (A) Each quality pool must be distributed by | ||||||
7 | assigning a quality weighted score for each nursing | ||||||
8 | home which is calculated by multiplying the nursing | ||||||
9 | home's quality base period Medicaid days by the | ||||||
10 | nursing home's star rating weight in that period. | ||||||
11 | (B) Star rating weights are assigned based on the | ||||||
12 | nursing home's star rating for the LTS quality star | ||||||
13 | rating. As used in this subparagraph, "LTS quality | ||||||
14 | star rating" means the long-term stay quality rating | ||||||
15 | for each nursing facility, as assigned by the Centers | ||||||
16 | for Medicare and Medicaid Services under the Five-Star | ||||||
17 | Quality Rating System. The rating is a number ranging | ||||||
18 | from 0 (lowest) to 5 (highest). | ||||||
19 | (i) Zero-star or one-star rating has a weight | ||||||
20 | of 0. | ||||||
21 | (ii) Two-star rating has a weight of 0.75. | ||||||
22 | (iii) Three-star rating has a weight of 1.5. | ||||||
23 | (iv) Four-star rating has a weight of 2.5. | ||||||
24 | (v) Five-star rating has a weight of 3.5. | ||||||
25 | (C) Each nursing home's quality weight score is | ||||||
26 | divided by the sum of all quality weight scores for |
| |||||||
| |||||||
1 | qualifying nursing homes to determine the proportion | ||||||
2 | of the quality pool to be paid to the nursing home. | ||||||
3 | (D) The quality pool is no less than $70,000,000 | ||||||
4 | annually or $17,500,000 per quarter. The Department | ||||||
5 | shall publish on its website the estimated payments | ||||||
6 | and the associated weights for each facility 45 days | ||||||
7 | prior to when the initial payments for the quarter are | ||||||
8 | to be paid. The Department shall assign each facility | ||||||
9 | the most recent and applicable quarter's STAR value | ||||||
10 | unless the facility notifies the Department within 15 | ||||||
11 | days of an issue and the facility provides reasonable | ||||||
12 | evidence demonstrating its timely compliance with | ||||||
13 | federal data submission requirements for the quarter | ||||||
14 | of record. If such evidence cannot be provided to the | ||||||
15 | Department, the STAR rating assigned to the facility | ||||||
16 | shall be reduced by one from the prior quarter. | ||||||
17 | (E) The Department shall review quality metrics | ||||||
18 | used for payment of the quality pool and make | ||||||
19 | recommendations for any associated changes to the | ||||||
20 | methodology for distributing quality pool payments in | ||||||
21 | consultation with associations representing long-term | ||||||
22 | care providers, consumer advocates, organizations | ||||||
23 | representing workers of long-term care facilities, and | ||||||
24 | payors. The Department may establish, by rule, changes | ||||||
25 | to the methodology for distributing quality pool | ||||||
26 | payments. |
| |||||||
| |||||||
1 | (F) The Department shall disburse quality pool | ||||||
2 | payments from the Long-Term Care Provider Fund on a | ||||||
3 | monthly basis in amounts proportional to the total | ||||||
4 | quality pool payment determined for the quarter. | ||||||
5 | (G) The Department shall publish any changes in | ||||||
6 | the methodology for distributing quality pool payments | ||||||
7 | prior to the beginning of the measurement period or | ||||||
8 | quality base period for any metric added to the | ||||||
9 | distribution's methodology. | ||||||
10 | (2) Payments based on CNA tenure, promotion, and CNA | ||||||
11 | training for the purpose of increasing CNA compensation. | ||||||
12 | It is the intent of this subsection that payments made in | ||||||
13 | accordance with this paragraph be directly incorporated | ||||||
14 | into increased compensation for CNAs. As used in this | ||||||
15 | paragraph, "CNA" means a certified nursing assistant as | ||||||
16 | that term is described in Section 3-206 of the Nursing | ||||||
17 | Home Care Act, Section 3-206 of the ID/DD Community Care | ||||||
18 | Act, and Section 3-206 of the MC/DD Act. The Department | ||||||
19 | shall establish, by rule, payments to nursing facilities | ||||||
20 | equal to Medicaid's share of the tenure wage increments | ||||||
21 | specified in this paragraph for all reported CNA employee | ||||||
22 | hours compensated according to a posted schedule | ||||||
23 | consisting of increments at least as large as those | ||||||
24 | specified in this paragraph. The increments are as | ||||||
25 | follows: an additional $1.50 per hour for CNAs with at | ||||||
26 | least one and less than 2 years' experience plus another |
| |||||||
| |||||||
1 | $1 per hour for each additional year of experience up to a | ||||||
2 | maximum of $6.50 for CNAs with at least 6 years of | ||||||
3 | experience. For purposes of this paragraph, Medicaid's | ||||||
4 | share shall be the ratio determined by paid Medicaid bed | ||||||
5 | days divided by total bed days for the applicable time | ||||||
6 | period used in the calculation. In addition, and additive | ||||||
7 | to any tenure increments paid as specified in this | ||||||
8 | paragraph, the Department shall establish, by rule, | ||||||
9 | payments supporting Medicaid's share of the | ||||||
10 | promotion-based wage increments for CNA employee hours | ||||||
11 | compensated for that promotion with at least a $1.50 | ||||||
12 | hourly increase. Medicaid's share shall be established as | ||||||
13 | it is for the tenure increments described in this | ||||||
14 | paragraph. Qualifying promotions shall be defined by the | ||||||
15 | Department in rules for an expected 10-15% subset of CNAs | ||||||
16 | assigned intermediate, specialized, or added roles such as | ||||||
17 | CNA trainers, CNA scheduling "captains", and CNA | ||||||
18 | specialists for resident conditions like dementia or | ||||||
19 | memory care or behavioral health. | ||||||
20 | (m) The Department shall work with nursing facility | ||||||
21 | industry representatives to design policies and procedures to | ||||||
22 | permit facilities to address the integrity of data from | ||||||
23 | federal reporting sites used by the Department in setting | ||||||
24 | facility rates. | ||||||
25 | (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21; | ||||||
26 | 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102, |
| |||||||
| |||||||
1 | Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50, | ||||||
2 | Section 50-5, eff. 1-1-24; revised 12-15-23.) | ||||||
3 | ARTICLE 185. | ||||||
4 | Section 185-5. The Illinois Public Aid Code is amended by | ||||||
5 | changing Section 5-5a.1 as follows: | ||||||
6 | (305 ILCS 5/5-5a.1) | ||||||
7 | Sec. 5-5a.1. Telehealth services for persons with | ||||||
8 | intellectual and developmental disabilities. The Department | ||||||
9 | shall file an amendment to the Home and Community-Based | ||||||
10 | Services Waiver Program for Adults with Developmental | ||||||
11 | Disabilities authorized under Section 1915(c) of the Social | ||||||
12 | Security Act to incorporate telehealth services administered | ||||||
13 | by a provider of telehealth services that demonstrates | ||||||
14 | knowledge and experience in providing medical and emergency | ||||||
15 | services for persons with intellectual and developmental | ||||||
16 | disabilities. For dates of service on and after January 1, | ||||||
17 | 2025, the Department shall pay negotiated, agreed upon | ||||||
18 | administrative fees associated with implementing telehealth | ||||||
19 | services for persons with intellectual and developmental | ||||||
20 | disabilities who are receiving Community Integrated Living | ||||||
21 | Arrangement residential services under the Home and | ||||||
22 | Community-Based Services Waiver Program for Adults with | ||||||
23 | Developmental Disabilities. The implementation of telehealth |
| |||||||
| |||||||
1 | services shall not impede the choice of any individual | ||||||
2 | receiving waiver-funded services through the Home and | ||||||
3 | Community-Based Services Waiver Program for Adults with | ||||||
4 | Developmental Disabilities to receive in-person health care | ||||||
5 | services at any time. The Department shall ensure individuals | ||||||
6 | enrolled in the waiver, or their guardians, request to opt-in | ||||||
7 | to these services. For individuals who opt in, this service | ||||||
8 | shall be included in the individual's person-centered plan. | ||||||
9 | The use of telehealth services shall not be used for the | ||||||
10 | convenience of staff at any time nor shall it replace primary | ||||||
11 | care physician services. The Department shall pay | ||||||
12 | administrative fees associated with implementing telehealth | ||||||
13 | services for all persons with intellectual and developmental | ||||||
14 | disabilities who are receiving services under the Home and | ||||||
15 | Community-Based Services Waiver Program for Adults with | ||||||
16 | Developmental Disabilities. | ||||||
17 | (Source: P.A. 103-102, eff. 7-1-23.) | ||||||
18 | ARTICLE 190. | ||||||
19 | Section 190-5. The Pharmacy Practice Act is amended by | ||||||
20 | changing Sections 3 and 9.6 as follows: | ||||||
21 | (225 ILCS 85/3) | ||||||
22 | (Section scheduled to be repealed on January 1, 2028) | ||||||
23 | Sec. 3. Definitions. For the purpose of this Act, except |
| |||||||
| |||||||
1 | where otherwise limited therein: | ||||||
2 | (a) "Pharmacy" or "drugstore" means and includes every | ||||||
3 | store, shop, pharmacy department, or other place where | ||||||
4 | pharmacist care is provided by a pharmacist (1) where drugs, | ||||||
5 | medicines, or poisons are dispensed, sold or offered for sale | ||||||
6 | at retail, or displayed for sale at retail; or (2) where | ||||||
7 | prescriptions of physicians, dentists, advanced practice | ||||||
8 | registered nurses, physician assistants, veterinarians, | ||||||
9 | podiatric physicians, or optometrists, within the limits of | ||||||
10 | their licenses, are compounded, filled, or dispensed; or (3) | ||||||
11 | which has upon it or displayed within it, or affixed to or used | ||||||
12 | in connection with it, a sign bearing the word or words | ||||||
13 | "Pharmacist", "Druggist", "Pharmacy", "Pharmaceutical Care", | ||||||
14 | "Apothecary", "Drugstore", "Medicine Store", "Prescriptions", | ||||||
15 | "Drugs", "Dispensary", "Medicines", or any word or words of | ||||||
16 | similar or like import, either in the English language or any | ||||||
17 | other language; or (4) where the characteristic prescription | ||||||
18 | sign (Rx) or similar design is exhibited; or (5) any store, or | ||||||
19 | shop, or other place with respect to which any of the above | ||||||
20 | words, objects, signs or designs are used in any | ||||||
21 | advertisement. | ||||||
22 | (b) "Drugs" means and includes (1) articles recognized in | ||||||
23 | the official United States Pharmacopoeia/National Formulary | ||||||
24 | (USP/NF), or any supplement thereto and being intended for and | ||||||
25 | having for their main use the diagnosis, cure, mitigation, | ||||||
26 | treatment or prevention of disease in man or other animals, as |
| |||||||
| |||||||
1 | approved by the United States Food and Drug Administration, | ||||||
2 | but does not include devices or their components, parts, or | ||||||
3 | accessories; and (2) all other articles intended for and | ||||||
4 | having for their main use the diagnosis, cure, mitigation, | ||||||
5 | treatment or prevention of disease in man or other animals, as | ||||||
6 | approved by the United States Food and Drug Administration, | ||||||
7 | but does not include devices or their components, parts, or | ||||||
8 | accessories; and (3) articles (other than food) having for | ||||||
9 | their main use and intended to affect the structure or any | ||||||
10 | function of the body of man or other animals; and (4) articles | ||||||
11 | having for their main use and intended for use as a component | ||||||
12 | or any articles specified in clause (1), (2) or (3); but does | ||||||
13 | not include devices or their components, parts or accessories. | ||||||
14 | (c) "Medicines" means and includes all drugs intended for | ||||||
15 | human or veterinary use approved by the United States Food and | ||||||
16 | Drug Administration. | ||||||
17 | (d) "Practice of pharmacy" means: | ||||||
18 | (1) the interpretation and the provision of assistance | ||||||
19 | in the monitoring, evaluation, and implementation of | ||||||
20 | prescription drug orders; | ||||||
21 | (2) the dispensing of prescription drug orders; | ||||||
22 | (3) participation in drug and device selection; | ||||||
23 | (4) drug administration limited to the administration | ||||||
24 | of oral, topical, injectable, and inhalation as follows: | ||||||
25 | (A) in the context of patient education on the | ||||||
26 | proper use or delivery of medications; |
| |||||||
| |||||||
1 | (B) vaccination of patients 7 years of age and | ||||||
2 | older pursuant to a valid prescription or standing | ||||||
3 | order, by a physician licensed to practice medicine in | ||||||
4 | all its branches, except for vaccinations covered by | ||||||
5 | paragraph (15), upon completion of appropriate | ||||||
6 | training, including how to address contraindications | ||||||
7 | and adverse reactions set forth by rule, with | ||||||
8 | notification to the patient's physician and | ||||||
9 | appropriate record retention, or pursuant to hospital | ||||||
10 | pharmacy and therapeutics committee policies and | ||||||
11 | procedures. Eligible vaccines are those listed on the | ||||||
12 | U.S. Centers for Disease Control and Prevention (CDC) | ||||||
13 | Recommended Immunization Schedule, the CDC's Health | ||||||
14 | Information for International Travel, or the U.S. Food | ||||||
15 | and Drug Administration's Vaccines Licensed and | ||||||
16 | Authorized for Use in the United States. As applicable | ||||||
17 | to the State's Medicaid program and other payers, | ||||||
18 | vaccines ordered and administered in accordance with | ||||||
19 | this subsection shall be covered and reimbursed at no | ||||||
20 | less than the rate that the vaccine is reimbursed when | ||||||
21 | ordered and administered by a physician; | ||||||
22 | (B-5) following the initial administration of | ||||||
23 | long-acting or extended-release form opioid | ||||||
24 | antagonists by a physician licensed to practice | ||||||
25 | medicine in all its branches, administration of | ||||||
26 | injections of long-acting or extended-release form |
| |||||||
| |||||||
1 | opioid antagonists for the treatment of substance use | ||||||
2 | disorder, pursuant to a valid prescription by a | ||||||
3 | physician licensed to practice medicine in all its | ||||||
4 | branches, upon completion of appropriate training, | ||||||
5 | including how to address contraindications and adverse | ||||||
6 | reactions, including, but not limited to, respiratory | ||||||
7 | depression and the performance of cardiopulmonary | ||||||
8 | resuscitation, set forth by rule, with notification to | ||||||
9 | the patient's physician and appropriate record | ||||||
10 | retention, or pursuant to hospital pharmacy and | ||||||
11 | therapeutics committee policies and procedures; | ||||||
12 | (C) administration of injections of | ||||||
13 | alpha-hydroxyprogesterone caproate, pursuant to a | ||||||
14 | valid prescription, by a physician licensed to | ||||||
15 | practice medicine in all its branches, upon completion | ||||||
16 | of appropriate training, including how to address | ||||||
17 | contraindications and adverse reactions set forth by | ||||||
18 | rule, with notification to the patient's physician and | ||||||
19 | appropriate record retention, or pursuant to hospital | ||||||
20 | pharmacy and therapeutics committee policies and | ||||||
21 | procedures; and | ||||||
22 | (D) administration of injections of long-term | ||||||
23 | antipsychotic medications pursuant to a valid | ||||||
24 | prescription by a physician licensed to practice | ||||||
25 | medicine in all its branches, upon completion of | ||||||
26 | appropriate training conducted by an Accreditation |
| |||||||
| |||||||
1 | Council of Pharmaceutical Education accredited | ||||||
2 | provider, including how to address contraindications | ||||||
3 | and adverse reactions set forth by rule, with | ||||||
4 | notification to the patient's physician and | ||||||
5 | appropriate record retention, or pursuant to hospital | ||||||
6 | pharmacy and therapeutics committee policies and | ||||||
7 | procedures. | ||||||
8 | (5) (blank); | ||||||
9 | (6) drug regimen review; | ||||||
10 | (7) drug or drug-related research; | ||||||
11 | (8) the provision of patient counseling; | ||||||
12 | (9) the practice of telepharmacy; | ||||||
13 | (10) the provision of those acts or services necessary | ||||||
14 | to provide pharmacist care; | ||||||
15 | (11) medication therapy management; | ||||||
16 | (12) the responsibility for compounding and labeling | ||||||
17 | of drugs and devices (except labeling by a manufacturer, | ||||||
18 | repackager, or distributor of non-prescription drugs and | ||||||
19 | commercially packaged legend drugs and devices), proper | ||||||
20 | and safe storage of drugs and devices, and maintenance of | ||||||
21 | required records; | ||||||
22 | (13) the assessment and consultation of patients and | ||||||
23 | dispensing of hormonal contraceptives; | ||||||
24 | (14) the initiation, dispensing, or administration of | ||||||
25 | drugs, laboratory tests, assessments, referrals, and | ||||||
26 | consultations for human immunodeficiency virus |
| |||||||
| |||||||
1 | pre-exposure prophylaxis and human immunodeficiency virus | ||||||
2 | post-exposure prophylaxis under Section 43.5; | ||||||
3 | (15) vaccination of patients 7 years of age and older | ||||||
4 | for COVID-19 or influenza subcutaneously, intramuscularly, | ||||||
5 | or orally as authorized, approved, or licensed by the | ||||||
6 | United States Food and Drug Administration, pursuant to | ||||||
7 | the following conditions: | ||||||
8 | (A) the vaccine must be authorized or licensed by | ||||||
9 | the United States Food and Drug Administration; | ||||||
10 | (B) the vaccine must be ordered and administered | ||||||
11 | according to the Advisory Committee on Immunization | ||||||
12 | Practices standard immunization schedule; | ||||||
13 | (C) the pharmacist must complete a course of | ||||||
14 | training accredited by the Accreditation Council on | ||||||
15 | Pharmacy Education or a similar health authority or | ||||||
16 | professional body approved by the Division of | ||||||
17 | Professional Regulation; | ||||||
18 | (D) the pharmacist must have a current certificate | ||||||
19 | in basic cardiopulmonary resuscitation; | ||||||
20 | (E) the pharmacist must complete, during each | ||||||
21 | State licensing period, a minimum of 2 hours of | ||||||
22 | immunization-related continuing pharmacy education | ||||||
23 | approved by the Accreditation Council on Pharmacy | ||||||
24 | Education; | ||||||
25 | (F) the pharmacist must comply with recordkeeping | ||||||
26 | and reporting requirements of the jurisdiction in |
| |||||||
| |||||||
1 | which the pharmacist administers vaccines, including | ||||||
2 | informing the patient's primary-care provider, when | ||||||
3 | available, and complying with requirements whereby the | ||||||
4 | person administering a vaccine must review the vaccine | ||||||
5 | registry or other vaccination records prior to | ||||||
6 | administering the vaccine; and | ||||||
7 | (G) the pharmacist must inform the pharmacist's | ||||||
8 | patients who are less than 18 years old, as well as the | ||||||
9 | adult caregiver accompanying the child, of the | ||||||
10 | importance of a well-child visit with a pediatrician | ||||||
11 | or other licensed primary-care provider and must refer | ||||||
12 | patients as appropriate; | ||||||
13 | (16) the ordering and administration of COVID-19 | ||||||
14 | therapeutics subcutaneously, intramuscularly, or orally | ||||||
15 | with notification to the patient's physician and | ||||||
16 | appropriate record retention or pursuant to hospital | ||||||
17 | pharmacy and therapeutics committee policies and | ||||||
18 | procedures. Eligible therapeutics are those approved, | ||||||
19 | authorized, or licensed by the United States Food and Drug | ||||||
20 | Administration and must be administered subcutaneously, | ||||||
21 | intramuscularly, or orally in accordance with that | ||||||
22 | approval, authorization, or licensing; and | ||||||
23 | (17) the ordering and administration of point of care | ||||||
24 | tests , and screenings , and treatments for (i) influenza, | ||||||
25 | (ii) SARS-CoV-2 SARS-COV 2 , (iii) Group A Streptococcus, | ||||||
26 | (iv) respiratory syncytial virus, (v) adult-stage head |
| |||||||
| |||||||
1 | louse, and (vi) (iii) health conditions identified by a | ||||||
2 | statewide public health emergency, as defined in the | ||||||
3 | Illinois Emergency Management Agency Act, with | ||||||
4 | notification to the patient's physician , if any, and | ||||||
5 | appropriate record retention or pursuant to hospital | ||||||
6 | pharmacy and therapeutics committee policies and | ||||||
7 | procedures. Eligible tests and screenings are those | ||||||
8 | approved, authorized, or licensed by the United States | ||||||
9 | Food and Drug Administration and must be administered in | ||||||
10 | accordance with that approval, authorization, or | ||||||
11 | licensing. | ||||||
12 | A pharmacist who orders or administers tests or | ||||||
13 | screenings for health conditions described in this | ||||||
14 | paragraph may use a test that may guide clinical | ||||||
15 | decision-making for the health condition that is waived | ||||||
16 | under the federal Clinical Laboratory Improvement | ||||||
17 | Amendments of 1988 and regulations promulgated thereunder | ||||||
18 | or any established screening procedure that is established | ||||||
19 | under a statewide protocol. | ||||||
20 | A pharmacist may delegate the administrative and | ||||||
21 | technical tasks of performing a test for the health | ||||||
22 | conditions described in this paragraph to a registered | ||||||
23 | pharmacy technician or student pharmacist acting under the | ||||||
24 | supervision of the pharmacist. | ||||||
25 | The testing, screening, and treatment ordered under | ||||||
26 | this paragraph by a pharmacist shall not be denied |
| |||||||
| |||||||
1 | reimbursement under health benefit plans that are within | ||||||
2 | the scope of the pharmacist's license and shall be covered | ||||||
3 | as if the services or procedures were performed by a | ||||||
4 | physician, an advanced practice registered nurse, or a | ||||||
5 | physician assistant. | ||||||
6 | A pharmacy benefit manager, health carrier, health | ||||||
7 | benefit plan, or third-party payor shall not discriminate | ||||||
8 | against a pharmacy or a pharmacist with respect to | ||||||
9 | participation referral, reimbursement of a covered | ||||||
10 | service, or indemnification if a pharmacist is acting | ||||||
11 | within the scope of the pharmacist's license and the | ||||||
12 | pharmacy is operating in compliance with all applicable | ||||||
13 | laws and rules. | ||||||
14 | A pharmacist who performs any of the acts defined as the | ||||||
15 | practice of pharmacy in this State must be actively licensed | ||||||
16 | as a pharmacist under this Act. | ||||||
17 | (e) "Prescription" means and includes any written, oral, | ||||||
18 | facsimile, or electronically transmitted order for drugs or | ||||||
19 | medical devices, issued by a physician licensed to practice | ||||||
20 | medicine in all its branches, dentist, veterinarian, podiatric | ||||||
21 | physician, or optometrist, within the limits of his or her | ||||||
22 | license, by a physician assistant in accordance with | ||||||
23 | subsection (f) of Section 4, or by an advanced practice | ||||||
24 | registered nurse in accordance with subsection (g) of Section | ||||||
25 | 4, containing the following: (1) name of the patient; (2) date | ||||||
26 | when prescription was issued; (3) name and strength of drug or |
| |||||||
| |||||||
1 | description of the medical device prescribed; and (4) | ||||||
2 | quantity; (5) directions for use; (6) prescriber's name, | ||||||
3 | address, and signature; and (7) DEA registration number where | ||||||
4 | required, for controlled substances. The prescription may, but | ||||||
5 | is not required to, list the illness, disease, or condition | ||||||
6 | for which the drug or device is being prescribed. DEA | ||||||
7 | registration numbers shall not be required on inpatient drug | ||||||
8 | orders. A prescription for medication other than controlled | ||||||
9 | substances shall be valid for up to 15 months from the date | ||||||
10 | issued for the purpose of refills, unless the prescription | ||||||
11 | states otherwise. | ||||||
12 | (f) "Person" means and includes a natural person, | ||||||
13 | partnership, association, corporation, government entity, or | ||||||
14 | any other legal entity. | ||||||
15 | (g) "Department" means the Department of Financial and | ||||||
16 | Professional Regulation. | ||||||
17 | (h) "Board of Pharmacy" or "Board" means the State Board | ||||||
18 | of Pharmacy of the Department of Financial and Professional | ||||||
19 | Regulation. | ||||||
20 | (i) "Secretary" means the Secretary of Financial and | ||||||
21 | Professional Regulation. | ||||||
22 | (j) "Drug product selection" means the interchange for a | ||||||
23 | prescribed pharmaceutical product in accordance with Section | ||||||
24 | 25 of this Act and Section 3.14 of the Illinois Food, Drug and | ||||||
25 | Cosmetic Act. | ||||||
26 | (k) "Inpatient drug order" means an order issued by an |
| |||||||
| |||||||
1 | authorized prescriber for a resident or patient of a facility | ||||||
2 | licensed under the Nursing Home Care Act, the ID/DD Community | ||||||
3 | Care Act, the MC/DD Act, the Specialized Mental Health | ||||||
4 | Rehabilitation Act of 2013, the Hospital Licensing Act, or the | ||||||
5 | University of Illinois Hospital Act, or a facility which is | ||||||
6 | operated by the Department of Human Services (as successor to | ||||||
7 | the Department of Mental Health and Developmental | ||||||
8 | Disabilities) or the Department of Corrections. | ||||||
9 | (k-5) "Pharmacist" means an individual health care | ||||||
10 | professional and provider currently licensed by this State to | ||||||
11 | engage in the practice of pharmacy. | ||||||
12 | (l) "Pharmacist in charge" means the licensed pharmacist | ||||||
13 | whose name appears on a pharmacy license and who is | ||||||
14 | responsible for all aspects of the operation related to the | ||||||
15 | practice of pharmacy. | ||||||
16 | (m) "Dispense" or "dispensing" means the interpretation, | ||||||
17 | evaluation, and implementation of a prescription drug order, | ||||||
18 | including the preparation and delivery of a drug or device to a | ||||||
19 | patient or patient's agent in a suitable container | ||||||
20 | appropriately labeled for subsequent administration to or use | ||||||
21 | by a patient in accordance with applicable State and federal | ||||||
22 | laws and regulations. "Dispense" or "dispensing" does not mean | ||||||
23 | the physical delivery to a patient or a patient's | ||||||
24 | representative in a home or institution by a designee of a | ||||||
25 | pharmacist or by common carrier. "Dispense" or "dispensing" | ||||||
26 | also does not mean the physical delivery of a drug or medical |
| |||||||
| |||||||
1 | device to a patient or patient's representative by a | ||||||
2 | pharmacist's designee within a pharmacy or drugstore while the | ||||||
3 | pharmacist is on duty and the pharmacy is open. | ||||||
4 | (n) "Nonresident pharmacy" means a pharmacy that is | ||||||
5 | located in a state, commonwealth, or territory of the United | ||||||
6 | States, other than Illinois, that delivers, dispenses, or | ||||||
7 | distributes, through the United States Postal Service, | ||||||
8 | commercially acceptable parcel delivery service, or other | ||||||
9 | common carrier, to Illinois residents, any substance which | ||||||
10 | requires a prescription. | ||||||
11 | (o) "Compounding" means the preparation and mixing of | ||||||
12 | components, excluding flavorings, (1) as the result of a | ||||||
13 | prescriber's prescription drug order or initiative based on | ||||||
14 | the prescriber-patient-pharmacist relationship in the course | ||||||
15 | of professional practice or (2) for the purpose of, or | ||||||
16 | incident to, research, teaching, or chemical analysis and not | ||||||
17 | for sale or dispensing. "Compounding" includes the preparation | ||||||
18 | of drugs or devices in anticipation of receiving prescription | ||||||
19 | drug orders based on routine, regularly observed dispensing | ||||||
20 | patterns. Commercially available products may be compounded | ||||||
21 | for dispensing to individual patients only if all of the | ||||||
22 | following conditions are met: (i) the commercial product is | ||||||
23 | not reasonably available from normal distribution channels in | ||||||
24 | a timely manner to meet the patient's needs and (ii) the | ||||||
25 | prescribing practitioner has requested that the drug be | ||||||
26 | compounded. |
| |||||||
| |||||||
1 | (p) (Blank). | ||||||
2 | (q) (Blank). | ||||||
3 | (r) "Patient counseling" means the communication between a | ||||||
4 | pharmacist or a student pharmacist under the supervision of a | ||||||
5 | pharmacist and a patient or the patient's representative about | ||||||
6 | the patient's medication or device for the purpose of | ||||||
7 | optimizing proper use of prescription medications or devices. | ||||||
8 | "Patient counseling" may include without limitation (1) | ||||||
9 | obtaining a medication history; (2) acquiring a patient's | ||||||
10 | allergies and health conditions; (3) facilitation of the | ||||||
11 | patient's understanding of the intended use of the medication; | ||||||
12 | (4) proper directions for use; (5) significant potential | ||||||
13 | adverse events; (6) potential food-drug interactions; and (7) | ||||||
14 | the need to be compliant with the medication therapy. A | ||||||
15 | pharmacy technician may only participate in the following | ||||||
16 | aspects of patient counseling under the supervision of a | ||||||
17 | pharmacist: (1) obtaining medication history; (2) providing | ||||||
18 | the offer for counseling by a pharmacist or student | ||||||
19 | pharmacist; and (3) acquiring a patient's allergies and health | ||||||
20 | conditions. | ||||||
21 | (s) "Patient profiles" or "patient drug therapy record" | ||||||
22 | means the obtaining, recording, and maintenance of patient | ||||||
23 | prescription information, including prescriptions for | ||||||
24 | controlled substances, and personal information. | ||||||
25 | (t) (Blank). | ||||||
26 | (u) "Medical device" or "device" means an instrument, |
| |||||||
| |||||||
1 | apparatus, implement, machine, contrivance, implant, in vitro | ||||||
2 | reagent, or other similar or related article, including any | ||||||
3 | component part or accessory, required under federal law to | ||||||
4 | bear the label "Caution: Federal law requires dispensing by or | ||||||
5 | on the order of a physician". A seller of goods and services | ||||||
6 | who, only for the purpose of retail sales, compounds, sells, | ||||||
7 | rents, or leases medical devices shall not, by reasons | ||||||
8 | thereof, be required to be a licensed pharmacy. | ||||||
9 | (v) "Unique identifier" means an electronic signature, | ||||||
10 | handwritten signature or initials, thumb print, or other | ||||||
11 | acceptable biometric or electronic identification process as | ||||||
12 | approved by the Department. | ||||||
13 | (w) "Current usual and customary retail price" means the | ||||||
14 | price that a pharmacy charges to a non-third-party payor. | ||||||
15 | (x) "Automated pharmacy system" means a mechanical system | ||||||
16 | located within the confines of the pharmacy or remote location | ||||||
17 | that performs operations or activities, other than compounding | ||||||
18 | or administration, relative to storage, packaging, dispensing, | ||||||
19 | or distribution of medication, and which collects, controls, | ||||||
20 | and maintains all transaction information. | ||||||
21 | (y) "Drug regimen review" means and includes the | ||||||
22 | evaluation of prescription drug orders and patient records for | ||||||
23 | (1) known allergies; (2) drug or potential therapy | ||||||
24 | contraindications; (3) reasonable dose, duration of use, and | ||||||
25 | route of administration, taking into consideration factors | ||||||
26 | such as age, gender, and contraindications; (4) reasonable |
| |||||||
| |||||||
1 | directions for use; (5) potential or actual adverse drug | ||||||
2 | reactions; (6) drug-drug interactions; (7) drug-food | ||||||
3 | interactions; (8) drug-disease contraindications; (9) | ||||||
4 | therapeutic duplication; (10) patient laboratory values when | ||||||
5 | authorized and available; (11) proper utilization (including | ||||||
6 | over or under utilization) and optimum therapeutic outcomes; | ||||||
7 | and (12) abuse and misuse. | ||||||
8 | (z) "Electronically transmitted prescription" means a | ||||||
9 | prescription that is created, recorded, or stored by | ||||||
10 | electronic means; issued and validated with an electronic | ||||||
11 | signature; and transmitted by electronic means directly from | ||||||
12 | the prescriber to a pharmacy. An electronic prescription is | ||||||
13 | not an image of a physical prescription that is transferred by | ||||||
14 | electronic means from computer to computer, facsimile to | ||||||
15 | facsimile, or facsimile to computer. | ||||||
16 | (aa) "Medication therapy management services" means a | ||||||
17 | distinct service or group of services offered by licensed | ||||||
18 | pharmacists, physicians licensed to practice medicine in all | ||||||
19 | its branches, advanced practice registered nurses authorized | ||||||
20 | in a written agreement with a physician licensed to practice | ||||||
21 | medicine in all its branches, or physician assistants | ||||||
22 | authorized in guidelines by a supervising physician that | ||||||
23 | optimize therapeutic outcomes for individual patients through | ||||||
24 | improved medication use. In a retail or other non-hospital | ||||||
25 | pharmacy, medication therapy management services shall consist | ||||||
26 | of the evaluation of prescription drug orders and patient |
| |||||||
| |||||||
1 | medication records to resolve conflicts with the following: | ||||||
2 | (1) known allergies; | ||||||
3 | (2) drug or potential therapy contraindications; | ||||||
4 | (3) reasonable dose, duration of use, and route of | ||||||
5 | administration, taking into consideration factors such as | ||||||
6 | age, gender, and contraindications; | ||||||
7 | (4) reasonable directions for use; | ||||||
8 | (5) potential or actual adverse drug reactions; | ||||||
9 | (6) drug-drug interactions; | ||||||
10 | (7) drug-food interactions; | ||||||
11 | (8) drug-disease contraindications; | ||||||
12 | (9) identification of therapeutic duplication; | ||||||
13 | (10) patient laboratory values when authorized and | ||||||
14 | available; | ||||||
15 | (11) proper utilization (including over or under | ||||||
16 | utilization) and optimum therapeutic outcomes; and | ||||||
17 | (12) drug abuse and misuse. | ||||||
18 | "Medication therapy management services" includes the | ||||||
19 | following: | ||||||
20 | (1) documenting the services delivered and | ||||||
21 | communicating the information provided to patients' | ||||||
22 | prescribers within an appropriate time frame, not to | ||||||
23 | exceed 48 hours; | ||||||
24 | (2) providing patient counseling designed to enhance a | ||||||
25 | patient's understanding and the appropriate use of his or | ||||||
26 | her medications; and |
| |||||||
| |||||||
1 | (3) providing information, support services, and | ||||||
2 | resources designed to enhance a patient's adherence with | ||||||
3 | his or her prescribed therapeutic regimens. | ||||||
4 | "Medication therapy management services" may also include | ||||||
5 | patient care functions authorized by a physician licensed to | ||||||
6 | practice medicine in all its branches for his or her | ||||||
7 | identified patient or groups of patients under specified | ||||||
8 | conditions or limitations in a standing order from the | ||||||
9 | physician. | ||||||
10 | "Medication therapy management services" in a licensed | ||||||
11 | hospital may also include the following: | ||||||
12 | (1) reviewing assessments of the patient's health | ||||||
13 | status; and | ||||||
14 | (2) following protocols of a hospital pharmacy and | ||||||
15 | therapeutics committee with respect to the fulfillment of | ||||||
16 | medication orders. | ||||||
17 | (bb) "Pharmacist care" means the provision by a pharmacist | ||||||
18 | of medication therapy management services, with or without the | ||||||
19 | dispensing of drugs or devices, intended to achieve outcomes | ||||||
20 | that improve patient health, quality of life, and comfort and | ||||||
21 | enhance patient safety. | ||||||
22 | (cc) "Protected health information" means individually | ||||||
23 | identifiable health information that, except as otherwise | ||||||
24 | provided, is: | ||||||
25 | (1) transmitted by electronic media; | ||||||
26 | (2) maintained in any medium set forth in the |
| |||||||
| |||||||
1 | definition of "electronic media" in the federal Health | ||||||
2 | Insurance Portability and Accountability Act; or | ||||||
3 | (3) transmitted or maintained in any other form or | ||||||
4 | medium. | ||||||
5 | "Protected health information" does not include | ||||||
6 | individually identifiable health information found in: | ||||||
7 | (1) education records covered by the federal Family | ||||||
8 | Educational Right and Privacy Act; or | ||||||
9 | (2) employment records held by a licensee in its role | ||||||
10 | as an employer. | ||||||
11 | (dd) "Standing order" means a specific order for a patient | ||||||
12 | or group of patients issued by a physician licensed to | ||||||
13 | practice medicine in all its branches in Illinois. | ||||||
14 | (ee) "Address of record" means the designated address | ||||||
15 | recorded by the Department in the applicant's application file | ||||||
16 | or licensee's license file maintained by the Department's | ||||||
17 | licensure maintenance unit. | ||||||
18 | (ff) "Home pharmacy" means the location of a pharmacy's | ||||||
19 | primary operations. | ||||||
20 | (gg) "Email address of record" means the designated email | ||||||
21 | address recorded by the Department in the applicant's | ||||||
22 | application file or the licensee's license file, as maintained | ||||||
23 | by the Department's licensure maintenance unit. | ||||||
24 | (Source: P.A. 102-16, eff. 6-17-21; 102-103, eff. 1-1-22; | ||||||
25 | 102-558, eff. 8-20-21; 102-813, eff. 5-13-22; 102-1051, eff. | ||||||
26 | 1-1-23; 103-1, eff. 4-27-23.) |
| |||||||
| |||||||
1 | (225 ILCS 85/9.6) | ||||||
2 | Sec. 9.6. Administration of vaccines and therapeutics by | ||||||
3 | registered pharmacy technicians and student pharmacists. | ||||||
4 | (a) Under the supervision of an appropriately trained | ||||||
5 | pharmacist, a registered pharmacy technician or student | ||||||
6 | pharmacist may administer COVID-19 , SARS-CoV-2, respiratory | ||||||
7 | syncytial virus, and influenza vaccines subcutaneously, | ||||||
8 | intramuscularly, or orally as authorized, approved, or | ||||||
9 | licensed by the United States Food and Drug Administration, | ||||||
10 | subject to the following conditions: | ||||||
11 | (1) the vaccination must be ordered by the supervising | ||||||
12 | pharmacist; | ||||||
13 | (2) the supervising pharmacist must be readily and | ||||||
14 | immediately available to the immunizing pharmacy | ||||||
15 | technician or student pharmacist; | ||||||
16 | (3) the pharmacy technician or student pharmacist must | ||||||
17 | complete a practical training program that is approved by | ||||||
18 | the Accreditation Council for Pharmacy Education and that | ||||||
19 | includes hands-on injection technique training and | ||||||
20 | training in the recognition and treatment of emergency | ||||||
21 | reactions to vaccines; | ||||||
22 | (4) the pharmacy technician or student pharmacist must | ||||||
23 | have a current certificate in basic cardiopulmonary | ||||||
24 | resuscitation; | ||||||
25 | (5) the pharmacy technician or student pharmacist must |
| |||||||
| |||||||
1 | complete, during the relevant licensing period, a minimum | ||||||
2 | of 2 hours of immunization-related continuing pharmacy | ||||||
3 | education that is approved by the Accreditation Council | ||||||
4 | for Pharmacy Education; | ||||||
5 | (6) the supervising pharmacist must comply with all | ||||||
6 | relevant recordkeeping and reporting requirements; | ||||||
7 | (7) the supervising pharmacist must be responsible for | ||||||
8 | complying with requirements related to reporting adverse | ||||||
9 | events; | ||||||
10 | (8) the supervising pharmacist must review the vaccine | ||||||
11 | registry or other vaccination records prior to ordering | ||||||
12 | the vaccination to be administered by the pharmacy | ||||||
13 | technician or student pharmacist; | ||||||
14 | (9) the pharmacy technician or student pharmacist | ||||||
15 | must, if the patient is 18 years of age or younger, inform | ||||||
16 | the patient and the adult caregiver accompanying the | ||||||
17 | patient of the importance of a well-child visit with a | ||||||
18 | pediatrician or other licensed primary-care provider and | ||||||
19 | must refer patients as appropriate; | ||||||
20 | (10) in the case of a COVID-19 vaccine, the | ||||||
21 | vaccination must be ordered and administered according to | ||||||
22 | the Advisory Committee on Immunization Practices' COVID-19 | ||||||
23 | vaccine recommendations; | ||||||
24 | (11) in the case of a COVID-19 vaccine, the | ||||||
25 | supervising pharmacist must comply with any applicable | ||||||
26 | requirements or conditions of use as set forth in the |
| |||||||
| |||||||
1 | Centers for Disease Control and Prevention COVID-19 | ||||||
2 | vaccination provider agreement and any other federal | ||||||
3 | requirements that apply to the administration of COVID-19 | ||||||
4 | vaccines being administered; and | ||||||
5 | (12) the registered pharmacy technician or student | ||||||
6 | pharmacist and the supervising pharmacist must comply with | ||||||
7 | all other requirements of this Act and the rules adopted | ||||||
8 | thereunder pertaining to the administration of drugs. | ||||||
9 | (b) Under the supervision of an appropriately trained | ||||||
10 | pharmacist, a registered pharmacy technician or student | ||||||
11 | pharmacist may administer COVID-19 therapeutics | ||||||
12 | subcutaneously, intramuscularly, or orally as authorized, | ||||||
13 | approved, or licensed by the United States Food and Drug | ||||||
14 | Administration, subject to the following conditions: | ||||||
15 | (1) the COVID-19 therapeutic must be authorized, | ||||||
16 | approved or licensed by the United States Food and Drug | ||||||
17 | Administration; | ||||||
18 | (2) the COVID-19 therapeutic must be administered | ||||||
19 | subcutaneously, intramuscularly, or orally in accordance | ||||||
20 | with the United States Food and Drug Administration | ||||||
21 | approval, authorization, or licensing; | ||||||
22 | (3) a pharmacy technician or student pharmacist | ||||||
23 | practicing pursuant to this Section must complete a | ||||||
24 | practical training program that is approved by the | ||||||
25 | Accreditation Council for Pharmacy Education and that | ||||||
26 | includes hands-on injection technique training, clinical |
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1 | evaluation of indications and contraindications of | ||||||
2 | COVID-19 therapeutics training, training in the | ||||||
3 | recognition and treatment of emergency reactions to | ||||||
4 | COVID-19 therapeutics, and any additional training | ||||||
5 | required in the United States Food and Drug Administration | ||||||
6 | approval, authorization, or licensing; | ||||||
7 | (4) the pharmacy technician or student pharmacist must | ||||||
8 | have a current certificate in basic cardiopulmonary | ||||||
9 | resuscitation; | ||||||
10 | (5) the pharmacy technician or student pharmacist must | ||||||
11 | comply with any applicable requirements or conditions of | ||||||
12 | use that apply to the administration of COVID-19 | ||||||
13 | therapeutics; | ||||||
14 | (6) the supervising pharmacist must comply with all | ||||||
15 | relevant recordkeeping and reporting requirements; | ||||||
16 | (7) the supervising pharmacist must be readily and | ||||||
17 | immediately available to the pharmacy technician or | ||||||
18 | student pharmacist; and | ||||||
19 | (8) the registered pharmacy technician or student | ||||||
20 | pharmacist and the supervising pharmacist must comply with | ||||||
21 | all other requirements of this Act and the rules adopted | ||||||
22 | thereunder pertaining to the administration of drugs. | ||||||
23 | (Source: P.A. 103-1, eff. 4-27-23.) | ||||||
24 | ARTICLE 999. |
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1 | Section 999-99. Effective date. This Act takes effect upon | ||||||
2 | becoming law.". |