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1 | AN ACT concerning State government.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 1. The Department of Human Services Act is amended | ||||||
5 | by adding Section 10-66 as follows: | ||||||
6 | (20 ILCS 1305/10-66 new) | ||||||
7 | Sec. 10-66. Rate reductions. Rates for medical services | ||||||
8 | purchased by the Divisions of Alcohol and Substance Abuse, | ||||||
9 | Community Health and Prevention, Developmental Disabilities, | ||||||
10 | Mental Health, or Rehabilitation Services within the | ||||||
11 | Department of Human Services shall not be reduced below the | ||||||
12 | rates calculated on April 1, 2011 unless the Department of | ||||||
13 | Human Services promulgates rules and rules are implemented | ||||||
14 | authorizing rate reductions. | ||||||
15 | Section 2. The Civil Administrative Code of Illinois is | ||||||
16 | amended by changing Section 2310-315 as follows:
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17 | (20 ILCS 2310/2310-315) (was 20 ILCS 2310/55.41)
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18 | Sec. 2310-315. Prevention and treatment of AIDS. To perform | ||||||
19 | the
following in relation to the prevention and
treatment of | ||||||
20 | acquired immunodeficiency syndrome (AIDS):
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21 | (1) Establish a State AIDS Control Unit within the |
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1 | Department as
a
separate administrative subdivision, to | ||||||
2 | coordinate all State
programs and services relating to the | ||||||
3 | prevention, treatment, and
amelioration of AIDS.
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4 | (2) Conduct a public information campaign for physicians,
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5 | hospitals, health facilities, public health departments, law | ||||||
6 | enforcement
personnel, public employees, laboratories, and the | ||||||
7 | general public on
acquired immunodeficiency syndrome (AIDS) | ||||||
8 | and promote necessary measures
to reduce the incidence of AIDS | ||||||
9 | and the mortality from AIDS. This program
shall include, but | ||||||
10 | not be limited to, the establishment of a statewide
hotline and | ||||||
11 | a State AIDS information clearinghouse that will provide
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12 | periodic reports and releases to public officials, health | ||||||
13 | professionals,
community service organizations, and the | ||||||
14 | general public regarding new
developments or procedures | ||||||
15 | concerning prevention and treatment of AIDS.
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16 | (3) (Blank).
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17 | (4) Establish alternative blood test services that are not
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18 | operated by a blood bank, plasma center or hospital. The
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19 | Department shall prescribe by rule minimum criteria, standards | ||||||
20 | and
procedures for the establishment and operation of such | ||||||
21 | services, which shall
include, but not be limited to | ||||||
22 | requirements for the provision of
information, counseling and | ||||||
23 | referral services that ensure appropriate
counseling and | ||||||
24 | referral for persons whose blood is tested and shows evidence | ||||||
25 | of
exposure to the human immunodeficiency virus (HIV) or other
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26 | identified causative agent of acquired immunodeficiency |
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1 | syndrome (AIDS).
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2 | (5) Establish regional and community service networks of | ||||||
3 | public
and
private service providers or health care | ||||||
4 | professionals who may be involved
in AIDS research, prevention | ||||||
5 | and treatment.
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6 | (6) Provide grants to individuals, organizations or | ||||||
7 | facilities
to support
the following:
| ||||||
8 | (A) Information, referral, and treatment
services.
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9 | (B) Interdisciplinary workshops for professionals | ||||||
10 | involved in
research and treatment.
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11 | (C) Establishment and operation of a statewide
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12 | hotline.
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13 | (D) Establishment and operation of alternative testing
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14 | services.
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15 | (E) Research into detection, prevention, and
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16 | treatment.
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17 | (F) Supplementation of other public and private
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18 | resources.
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19 | (G) Implementation by long-term care facilities of | ||||||
20 | Department
standards and procedures for the care and | ||||||
21 | treatment of persons with AIDS
and the development of | ||||||
22 | adequate numbers and types of placements for those
persons.
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23 | (7) (Blank).
| ||||||
24 | (8) Accept any gift, donation, bequest, or grant of funds
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25 | from private or
public agencies, including federal funds that | ||||||
26 | may be provided for AIDS control
efforts.
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1 | (9) Develop and implement, in consultation with the | ||||||
2 | Long-Term
Care
Facility Advisory Board, standards and | ||||||
3 | procedures for long-term care
facilities that provide care and | ||||||
4 | treatment of persons with AIDS, including
appropriate | ||||||
5 | infection control procedures. The Department shall work
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6 | cooperatively with organizations representing those facilities | ||||||
7 | to
develop
adequate numbers and types of placements for persons | ||||||
8 | with AIDS and shall
advise those facilities on proper | ||||||
9 | implementation of its standards
and procedures.
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10 | (10) The Department shall create and administer a training
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11 | program
for State employees who have a need for understanding | ||||||
12 | matters relating to
AIDS in order to deal with or advise the | ||||||
13 | public. The training
shall
include information on the cause and | ||||||
14 | effects of AIDS, the means of
detecting it and preventing its | ||||||
15 | transmission, the availability of related
counseling and | ||||||
16 | referral, and other matters that may be
appropriate.
The | ||||||
17 | training may also be made available to employees of local
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18 | governments,
public service agencies, and private agencies | ||||||
19 | that contract
with the State;
in those cases the Department may | ||||||
20 | charge a reasonable fee to
recover the
cost of the training.
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21 | (11) Approve tests or testing procedures used in | ||||||
22 | determining
exposure to HIV or any other identified causative | ||||||
23 | agent of AIDS.
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24 | (12) Provide prescription drug benefits counseling for | ||||||
25 | persons with HIV or AIDS.
| ||||||
26 | (13) Continue to administer the AIDS Drug Assistance |
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1 | Program that provides drugs to prolong the lives of low income | ||||||
2 | Persons with Acquired Immunodeficiency Syndrome (AIDS) or | ||||||
3 | Human Immunodeficiency Virus (HIV) infection who are not | ||||||
4 | eligible under Article V of the Illinois Public Aid Code for | ||||||
5 | Medical Assistance, as provided under Title 77, Chapter 1, | ||||||
6 | Subchapter (k), Part 692, Section 692.10 of the Illinois | ||||||
7 | Administrative Code, effective August 1, 2000, except that the | ||||||
8 | financial qualification for that program shall be that the | ||||||
9 | anticipated gross monthly income shall be at or below 500% of | ||||||
10 | the most recent Federal Poverty Guidelines published annually | ||||||
11 | by the United States Department of Health and Human Services | ||||||
12 | for the size of the household. Notwithstanding the preceding | ||||||
13 | sentence, the Department of Public Health may determine the | ||||||
14 | income eligibility standard for the AIDS Drug Assistance | ||||||
15 | Program each year and may set the standard at more than 500% of | ||||||
16 | the Federal Poverty Guidelines for the size of the household, | ||||||
17 | provided that moneys appropriated to the Department for the | ||||||
18 | program are sufficient to cover the increased cost of | ||||||
19 | implementing the higher income eligibility standard. | ||||||
20 | Rulemaking authority to implement this amendatory Act of the | ||||||
21 | 95th General Assembly, if any, is conditioned on the rules | ||||||
22 | being adopted in accordance with all provisions of the Illinois | ||||||
23 | Administrative Procedure Act and all rules and procedures of | ||||||
24 | the Joint Committee on Administrative Rules; any purported rule | ||||||
25 | not so adopted, for whatever reason, is unauthorized. If the | ||||||
26 | Department reduces the financial qualification for new |
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1 | applicants while allowing currently enrolled individuals to | ||||||
2 | remain on the program, the Department shall maintain a waiting | ||||||
3 | list of applicants who would otherwise be eligible except that | ||||||
4 | they do not meet the financial qualifications. Upon | ||||||
5 | determination that program finances are adequate, the | ||||||
6 | Department shall permit qualified individuals who are on the | ||||||
7 | waiting list to enroll in the program. | ||||||
8 | (14) In order to implement the provisions of Public Act | ||||||
9 | 95-7, the Department must expand HIV testing in health care | ||||||
10 | settings where undiagnosed individuals are likely to be | ||||||
11 | identified. The Department must purchase rapid HIV kits and | ||||||
12 | make grants for technical assistance, staff to conduct HIV | ||||||
13 | testing and counseling, and related purposes. The Department | ||||||
14 | must make grants to (i) facilities serving patients that are | ||||||
15 | uninsured at high rates, (ii) facilities located in areas with | ||||||
16 | a high prevalence of HIV or AIDS, (iii) facilities that have a | ||||||
17 | high likelihood of identifying individuals who are undiagnosed | ||||||
18 | with HIV or AIDS, or (iv) any combination of items (i), (ii), | ||||||
19 | and (iii). | ||||||
20 | (Source: P.A. 94-909, eff. 6-23-06; 95-744, eff. 7-18-08; | ||||||
21 | 95-1042, eff. 3-25-09.)
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22 | Section 3. The Disabled Persons Rehabilitation Act is | ||||||
23 | amended by adding Section 10a as follows: | ||||||
24 | (20 ILCS 2405/10a new) |
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1 | Sec. 10a. Financial Participation of Students Attending | ||||||
2 | the Illinois School for the Deaf and the Illinois School for | ||||||
3 | the Visually Impaired. | ||||||
4 | (a) General. The Illinois School for the Deaf and the | ||||||
5 | Illinois School for the Visually Impaired are required to | ||||||
6 | provide eligible students with disabilities with a free and | ||||||
7 | appropriate education. As part of the admission process to | ||||||
8 | either school, the Department shall complete a financial | ||||||
9 | analysis on each student attending the Illinois School for the | ||||||
10 | Deaf or the Illinois School for the Visually Impaired and shall | ||||||
11 | ask parents or guardians to participate, if applicable, in the | ||||||
12 | cost of identified services or activities that are not | ||||||
13 | education related. | ||||||
14 | (b) Completion of financial analysis.
Prior to admission, | ||||||
15 | and annually thereafter, a financial analysis shall be | ||||||
16 | completed on each student attending the Illinois School for the | ||||||
17 | Deaf or the Illinois School for the Visually Impaired. If at | ||||||
18 | any time there is reason to believe there is a change in the | ||||||
19 | student's financial situation that will affect their financial | ||||||
20 | participation, a new financial analysis shall be completed. | ||||||
21 | (1) In completing the student's financial analysis, | ||||||
22 | the income of the student's family shall be used. Proof of | ||||||
23 | income must be provided and retained for each parent or | ||||||
24 | guardian. | ||||||
25 | (2) Any funds that have been established on behalf of | ||||||
26 | the student for completion of their primary or secondary |
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1 | education shall be considered when completing the | ||||||
2 | financial analysis. | ||||||
3 | (3) Falsification of information used to complete the | ||||||
4 | financial analysis may result in the Department taking | ||||||
5 | action to recoup monies previously expended by the | ||||||
6 | Department in providing services to the student. | ||||||
7 | (c) Financial Participation. Utilizing a sliding scale | ||||||
8 | based on income standards developed by rule by the Department | ||||||
9 | with input from the superintendent of each school, parents or | ||||||
10 | guardians of students attending the Illinois School for the | ||||||
11 | Deaf or the Illinois School for the Visually Impaired may be | ||||||
12 | asked to financially participate in the following fees for | ||||||
13 | services or activities provided at the schools: | ||||||
14 | (1) Registration. | ||||||
15 | (2) Books, labs, and supplies (fees may vary depending | ||||||
16 | on the classes in which a student participates). | ||||||
17 | (3) Room and board for residential students. | ||||||
18 | (4) Meals for day students. | ||||||
19 | (5) Athletic or extracurricular activities (students | ||||||
20 | participating in multiple activities will not be required | ||||||
21 | to pay for more than 2 activities). | ||||||
22 | (6) Driver's education (if applicable). | ||||||
23 | (7) Graduation. | ||||||
24 | (8) Yearbook (optional). | ||||||
25 | (9) Activities (field trips or other leisure | ||||||
26 | activities). |
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1 | (10) Other activities or services identified by the | ||||||
2 | Department. | ||||||
3 | Students, parents, or guardians who are receiving Medicaid | ||||||
4 | or Temporary Assistance for Needy Families (TANF) shall not be | ||||||
5 | required to financially participate in the fees established in | ||||||
6 | this subsection (c). | ||||||
7 | Exceptions may be granted to parents or guardians who are | ||||||
8 | unable to meet the financial participation obligations due to | ||||||
9 | extenuating circumstances. Requests for exceptions must be | ||||||
10 | made in writing and must be submitted to the superintendent for | ||||||
11 | initial recommendation with a final determination by the | ||||||
12 | Director of the Division of Rehabilitation Services. | ||||||
13 | Any fees collected under this subsection (c) shall be held | ||||||
14 | locally by the school and used exclusively for the purpose for | ||||||
15 | which the fee was assessed. | ||||||
16 | Section 5. The State Prompt Payment Act is amended by | ||||||
17 | changing Section 3-2 as follows:
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18 | (30 ILCS 540/3-2)
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19 | Sec. 3-2. Beginning July 1, 1993, in any instance where a | ||||||
20 | State official or
agency is late in payment of a vendor's bill | ||||||
21 | or invoice for goods or services
furnished to the State, as | ||||||
22 | defined in Section 1, properly approved in
accordance with | ||||||
23 | rules promulgated under Section 3-3, the State official or
| ||||||
24 | agency shall pay interest to the vendor in accordance with the |
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1 | following:
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2 | (1) Any bill, except a bill submitted under Article V | ||||||
3 | of the Illinois Public Aid Code and except as provided | ||||||
4 | under paragraph (1.05) of this Section , approved for | ||||||
5 | payment under this Section must be paid
or the payment | ||||||
6 | issued to the payee within 60 days of receipt
of a proper | ||||||
7 | bill or invoice.
If payment is not issued to the payee | ||||||
8 | within this 60-day 60 day
period, an
interest penalty of | ||||||
9 | 1.0% of any amount approved and unpaid shall be added
for | ||||||
10 | each month or fraction thereof after the end of this 60-day | ||||||
11 | 60 day period,
until final payment is made. Any bill, | ||||||
12 | except a bill for pharmacy
or nursing facility services or | ||||||
13 | goods and except as provided under paragraph (1.05) of this | ||||||
14 | Section , submitted under Article V of the Illinois Public | ||||||
15 | Aid Code approved for payment under this Section must be | ||||||
16 | paid
or the payment issued to the payee within 60 days | ||||||
17 | after receipt
of a proper bill or invoice, and,
if payment | ||||||
18 | is not issued to the payee within this 60-day
period, an
| ||||||
19 | interest penalty of 2.0% of any amount approved and unpaid | ||||||
20 | shall be added
for each month or fraction thereof after the | ||||||
21 | end of this 60-day period,
until final payment is made. Any | ||||||
22 | bill for pharmacy or nursing facility services or
goods | ||||||
23 | submitted under Article V of the Illinois Public Aid
Code , | ||||||
24 | except as provided under paragraph (1.05) of this Section, | ||||||
25 | , approved for payment under this Section must be paid
or | ||||||
26 | the payment issued to the payee within 60 days of
receipt |
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1 | of a proper bill or invoice. If payment is not
issued to | ||||||
2 | the payee within this 60-day 60 day period, an interest
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3 | penalty of 1.0% of any amount approved and unpaid shall be
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4 | added for each month or fraction thereof after the end of | ||||||
5 | this 60-day 60 day period, until final payment is made.
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6 | (1.05) For State fiscal year 2012 and future fiscal | ||||||
7 | years, any bill approved for payment under this Section | ||||||
8 | must be paid
or the payment issued to the payee within 90 | ||||||
9 | days of receipt
of a proper bill or invoice.
If payment is | ||||||
10 | not issued to the payee within this 90-day
period, an
| ||||||
11 | interest penalty of 1.0% of any amount approved and unpaid | ||||||
12 | shall be added
for each month or fraction thereof after the | ||||||
13 | end of this 90-day period,
until final payment is made.
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14 | (1.1) A State agency shall review in a timely manner | ||||||
15 | each bill or
invoice after its receipt. If the
State agency | ||||||
16 | determines that the bill or invoice contains a defect | ||||||
17 | making it
unable to process the payment request, the agency
| ||||||
18 | shall notify the vendor requesting payment as soon as | ||||||
19 | possible after
discovering the
defect pursuant to rules | ||||||
20 | promulgated under Section 3-3; provided, however, that the | ||||||
21 | notice for construction related bills or invoices must be | ||||||
22 | given not later than 30 days after the bill or invoice was | ||||||
23 | first submitted. The notice shall
identify the defect and | ||||||
24 | any additional information
necessary to correct the | ||||||
25 | defect. If one or more items on a construction related bill | ||||||
26 | or invoice are disapproved, but not the entire bill or |
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1 | invoice, then the portion that is not disapproved shall be | ||||||
2 | paid.
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3 | (2) Where a State official or agency is late in payment | ||||||
4 | of a
vendor's bill or invoice properly approved in | ||||||
5 | accordance with this Act, and
different late payment terms | ||||||
6 | are not reduced to writing as a contractual
agreement, the | ||||||
7 | State official or agency shall automatically pay interest
| ||||||
8 | penalties required by this Section amounting to $50 or more | ||||||
9 | to the appropriate
vendor. Each agency shall be responsible | ||||||
10 | for determining whether an interest
penalty
is
owed and
for | ||||||
11 | paying the interest to the vendor.
Interest due to a vendor | ||||||
12 | that amounts to less than $50 shall not be paid but shall | ||||||
13 | be accrued until all interest due the vendor for all | ||||||
14 | similar warrants exceeds $50, at which time the accrued | ||||||
15 | interest shall be payable and interest will begin accruing | ||||||
16 | again, except that interest accrued as of the end of the | ||||||
17 | fiscal year that does not exceed $50 shall be payable at | ||||||
18 | that time. In the event an
individual has paid a vendor for | ||||||
19 | services in advance, the provisions of this
Section shall | ||||||
20 | apply until payment is made to that individual.
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21 | (3) The provisions of Public Act 96-1501 this | ||||||
22 | amendatory Act of the 96th General Assembly reducing the | ||||||
23 | interest rate on pharmacy claims under Article V of the | ||||||
24 | Illinois Public Aid Code to 1.0% per month shall apply to | ||||||
25 | any pharmacy bills for services and goods under Article V | ||||||
26 | of the Illinois Public Aid Code received on or after the |
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1 | date 60 days before January 25, 2011 ( the effective date of | ||||||
2 | Public Act 96-1501) except as provided under paragraph | ||||||
3 | (1.05) of this Section this amendatory Act of the 96th | ||||||
4 | General Assembly . | ||||||
5 | (Source: P.A. 96-555, eff. 8-18-09; 96-802, eff. 1-1-10; | ||||||
6 | 96-959, eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1501, eff. | ||||||
7 | 1-25-11; 96-1530, eff. 2-16-11; revised 2-22-11.)
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8 | Section 10. The Children's Health Insurance Program Act is | ||||||
9 | amended by changing Section 30 as follows:
| ||||||
10 | (215 ILCS 106/30)
| ||||||
11 | Sec. 30. Cost sharing.
| ||||||
12 | (a) Children enrolled in a health benefits program pursuant | ||||||
13 | to subdivision
(a)(2) of Section 25 and persons enrolled in a | ||||||
14 | health benefits waiver program pursuant to Section 40 shall be | ||||||
15 | subject to the following cost sharing
requirements:
| ||||||
16 | (1) There shall be no co-payment required for well-baby | ||||||
17 | or well-child
care, including age-appropriate | ||||||
18 | immunizations as required under
federal law.
| ||||||
19 | (2) Health insurance premiums for family members, | ||||||
20 | either children or adults, in families whose household
| ||||||
21 | income is above 150% of the federal poverty level shall be | ||||||
22 | payable
monthly, subject to rules promulgated by the | ||||||
23 | Department for grace periods and
advance payments, and | ||||||
24 | shall be as follows:
|
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| |||||||
1 | (A) $15 per month for one family member.
| ||||||
2 | (B) $25 per month for 2 family members.
| ||||||
3 | (C) $30 per month for 3 family members. | ||||||
4 | (D) $35 per month for 4 family members. | ||||||
5 | (E) $40 per month for 5 or more family members.
| ||||||
6 | (3) Co-payments for children or adults in families | ||||||
7 | whose income is at or below
150% of the federal poverty | ||||||
8 | level, at a minimum and to the extent permitted
under | ||||||
9 | federal law, shall be $2 for all medical visits and | ||||||
10 | prescriptions
provided under this Act and up to $10 for | ||||||
11 | emergency room use for a non-emergency situation as defined | ||||||
12 | by the Department by rule and subject to federal approval .
| ||||||
13 | (4) Co-payments for children or adults in families | ||||||
14 | whose income is above 150%
of the federal poverty level, at | ||||||
15 | a minimum and to the extent permitted under
federal law | ||||||
16 | shall be as follows:
| ||||||
17 | (A) $5 for medical visits.
| ||||||
18 | (B) $3 for generic prescriptions and $5 for brand | ||||||
19 | name
prescriptions.
| ||||||
20 | (C) $25 for emergency room use for a non-emergency
| ||||||
21 | situation as defined by the Department by rule.
| ||||||
22 | (5) (Blank) The maximum amount of out-of-pocket | ||||||
23 | expenses for co-payments shall be
$100 per family per year .
| ||||||
24 | (6) Co-payments shall be maximized to the extent | ||||||
25 | permitted by federal law and are subject to federal | ||||||
26 | approval. |
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| |||||||
1 | (b) Individuals enrolled in a privately sponsored health | ||||||
2 | insurance plan
pursuant to subdivision (a)(1) of Section 25 | ||||||
3 | shall be subject to the cost
sharing provisions as stated in | ||||||
4 | the privately sponsored health insurance plan.
| ||||||
5 | (Source: P.A. 94-48, eff. 7-1-05.)
| ||||||
6 | Section 15. The Illinois Public Aid Code is amended by | ||||||
7 | changing Sections 5-2, 5-4.1, 5-5.12, and 5A-10 as follows:
| ||||||
8 | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| ||||||
9 | Sec. 5-2. Classes of Persons Eligible. Medical assistance | ||||||
10 | under this
Article shall be available to any of the following | ||||||
11 | classes of persons in
respect to whom a plan for coverage has | ||||||
12 | been submitted to the Governor
by the Illinois Department and | ||||||
13 | approved by him:
| ||||||
14 | 1. Recipients of basic maintenance grants under | ||||||
15 | Articles III and IV.
| ||||||
16 | 2. Persons otherwise eligible for basic maintenance | ||||||
17 | under Articles
III and IV, excluding any eligibility | ||||||
18 | requirements that are inconsistent with any federal law or | ||||||
19 | federal regulation, as interpreted by the U.S. Department | ||||||
20 | of Health and Human Services, but who fail to qualify | ||||||
21 | thereunder on the basis of need or who qualify but are not | ||||||
22 | receiving basic maintenance under Article IV, and
who have | ||||||
23 | insufficient income and resources to meet the costs of
| ||||||
24 | necessary medical care, including but not limited to the |
| |||||||
| |||||||
1 | following:
| ||||||
2 | (a) All persons otherwise eligible for basic | ||||||
3 | maintenance under Article
III but who fail to qualify | ||||||
4 | under that Article on the basis of need and who
meet | ||||||
5 | either of the following requirements:
| ||||||
6 | (i) their income, as determined by the | ||||||
7 | Illinois Department in
accordance with any federal | ||||||
8 | requirements, is equal to or less than 70% in
| ||||||
9 | fiscal year 2001, equal to or less than 85% in | ||||||
10 | fiscal year 2002 and until
a date to be determined | ||||||
11 | by the Department by rule, and equal to or less
| ||||||
12 | than 100% beginning on the date determined by the | ||||||
13 | Department by rule, of the nonfarm income official | ||||||
14 | poverty
line, as defined by the federal Office of | ||||||
15 | Management and Budget and revised
annually in | ||||||
16 | accordance with Section 673(2) of the Omnibus | ||||||
17 | Budget Reconciliation
Act of 1981, applicable to | ||||||
18 | families of the same size; or
| ||||||
19 | (ii) their income, after the deduction of | ||||||
20 | costs incurred for medical
care and for other types | ||||||
21 | of remedial care, is equal to or less than 70% in
| ||||||
22 | fiscal year 2001, equal to or less than 85% in | ||||||
23 | fiscal year 2002 and until
a date to be determined | ||||||
24 | by the Department by rule, and equal to or less
| ||||||
25 | than 100% beginning on the date determined by the | ||||||
26 | Department by rule, of the nonfarm income official |
| |||||||
| |||||||
1 | poverty
line, as defined in item (i) of this | ||||||
2 | subparagraph (a).
| ||||||
3 | (b) All persons who, excluding any eligibility | ||||||
4 | requirements that are inconsistent with any federal | ||||||
5 | law or federal regulation, as interpreted by the U.S. | ||||||
6 | Department of Health and Human Services, would be | ||||||
7 | determined eligible for such basic
maintenance under | ||||||
8 | Article IV by disregarding the maximum earned income
| ||||||
9 | permitted by federal law.
| ||||||
10 | 3. Persons who would otherwise qualify for Aid to the | ||||||
11 | Medically
Indigent under Article VII.
| ||||||
12 | 4. Persons not eligible under any of the preceding | ||||||
13 | paragraphs who fall
sick, are injured, or die, not having | ||||||
14 | sufficient money, property or other
resources to meet the | ||||||
15 | costs of necessary medical care or funeral and burial
| ||||||
16 | expenses.
| ||||||
17 | 5.(a) Women during pregnancy, after the fact
of | ||||||
18 | pregnancy has been determined by medical diagnosis, and | ||||||
19 | during the
60-day period beginning on the last day of the | ||||||
20 | pregnancy, together with
their infants and children born | ||||||
21 | after September 30, 1983,
whose income and
resources are | ||||||
22 | insufficient to meet the costs of necessary medical care to
| ||||||
23 | the maximum extent possible under Title XIX of the
Federal | ||||||
24 | Social Security Act.
| ||||||
25 | (b) The Illinois Department and the Governor shall | ||||||
26 | provide a plan for
coverage of the persons eligible under |
| |||||||
| |||||||
1 | paragraph 5(a) by April 1, 1990. Such
plan shall provide | ||||||
2 | ambulatory prenatal care to pregnant women during a
| ||||||
3 | presumptive eligibility period and establish an income | ||||||
4 | eligibility standard
that is equal to 133%
of the nonfarm | ||||||
5 | income official poverty line, as defined by
the federal | ||||||
6 | Office of Management and Budget and revised annually in
| ||||||
7 | accordance with Section 673(2) of the Omnibus Budget | ||||||
8 | Reconciliation Act of
1981, applicable to families of the | ||||||
9 | same size, provided that costs incurred
for medical care | ||||||
10 | are not taken into account in determining such income
| ||||||
11 | eligibility.
| ||||||
12 | (c) The Illinois Department may conduct a | ||||||
13 | demonstration in at least one
county that will provide | ||||||
14 | medical assistance to pregnant women, together
with their | ||||||
15 | infants and children up to one year of age,
where the | ||||||
16 | income
eligibility standard is set up to 185% of the | ||||||
17 | nonfarm income official
poverty line, as defined by the | ||||||
18 | federal Office of Management and Budget.
The Illinois | ||||||
19 | Department shall seek and obtain necessary authorization
| ||||||
20 | provided under federal law to implement such a | ||||||
21 | demonstration. Such
demonstration may establish resource | ||||||
22 | standards that are not more
restrictive than those | ||||||
23 | established under Article IV of this Code.
| ||||||
24 | 6. Persons under the age of 18 who fail to qualify as | ||||||
25 | dependent under
Article IV and who have insufficient income | ||||||
26 | and resources to meet the costs
of necessary medical care |
| |||||||
| |||||||
1 | to the maximum extent permitted under Title XIX
of the | ||||||
2 | Federal Social Security Act.
| ||||||
3 | 7. Persons who are under 21 years of age and would
| ||||||
4 | qualify as
disabled as defined under the Federal | ||||||
5 | Supplemental Security Income Program,
provided medical | ||||||
6 | service for such persons would be eligible for Federal
| ||||||
7 | Financial Participation, and provided the Illinois | ||||||
8 | Department determines that:
| ||||||
9 | (a) the person requires a level of care provided by | ||||||
10 | a hospital, skilled
nursing facility, or intermediate | ||||||
11 | care facility, as determined by a physician
licensed to | ||||||
12 | practice medicine in all its branches;
| ||||||
13 | (b) it is appropriate to provide such care outside | ||||||
14 | of an institution, as
determined by a physician | ||||||
15 | licensed to practice medicine in all its branches;
| ||||||
16 | (c) the estimated amount which would be expended | ||||||
17 | for care outside the
institution is not greater than | ||||||
18 | the estimated amount which would be
expended in an | ||||||
19 | institution.
| ||||||
20 | 8. Persons who become ineligible for basic maintenance | ||||||
21 | assistance
under Article IV of this Code in programs | ||||||
22 | administered by the Illinois
Department due to employment | ||||||
23 | earnings and persons in
assistance units comprised of | ||||||
24 | adults and children who become ineligible for
basic | ||||||
25 | maintenance assistance under Article VI of this Code due to
| ||||||
26 | employment earnings. The plan for coverage for this class |
| |||||||
| |||||||
1 | of persons shall:
| ||||||
2 | (a) extend the medical assistance coverage for up | ||||||
3 | to 12 months following
termination of basic | ||||||
4 | maintenance assistance; and
| ||||||
5 | (b) offer persons who have initially received 6 | ||||||
6 | months of the
coverage provided in paragraph (a) above, | ||||||
7 | the option of receiving an
additional 6 months of | ||||||
8 | coverage, subject to the following:
| ||||||
9 | (i) such coverage shall be pursuant to | ||||||
10 | provisions of the federal
Social Security Act;
| ||||||
11 | (ii) such coverage shall include all services | ||||||
12 | covered while the person
was eligible for basic | ||||||
13 | maintenance assistance;
| ||||||
14 | (iii) no premium shall be charged for such | ||||||
15 | coverage; and
| ||||||
16 | (iv) such coverage shall be suspended in the | ||||||
17 | event of a person's
failure without good cause to | ||||||
18 | file in a timely fashion reports required for
this | ||||||
19 | coverage under the Social Security Act and | ||||||
20 | coverage shall be reinstated
upon the filing of | ||||||
21 | such reports if the person remains otherwise | ||||||
22 | eligible.
| ||||||
23 | 9. Persons with acquired immunodeficiency syndrome | ||||||
24 | (AIDS) or with
AIDS-related conditions with respect to whom | ||||||
25 | there has been a determination
that but for home or | ||||||
26 | community-based services such individuals would
require |
| |||||||
| |||||||
1 | the level of care provided in an inpatient hospital, | ||||||
2 | skilled
nursing facility or intermediate care facility the | ||||||
3 | cost of which is
reimbursed under this Article. Assistance | ||||||
4 | shall be provided to such
persons to the maximum extent | ||||||
5 | permitted under Title
XIX of the Federal Social Security | ||||||
6 | Act.
| ||||||
7 | 10. Participants in the long-term care insurance | ||||||
8 | partnership program
established under the Illinois | ||||||
9 | Long-Term Care Partnership Program Act who meet the
| ||||||
10 | qualifications for protection of resources described in | ||||||
11 | Section 15 of that
Act.
| ||||||
12 | 11. Persons with disabilities who are employed and | ||||||
13 | eligible for Medicaid,
pursuant to Section | ||||||
14 | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, | ||||||
15 | subject to federal approval, persons with a medically | ||||||
16 | improved disability who are employed and eligible for | ||||||
17 | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | ||||||
18 | the Social Security Act, as
provided by the Illinois | ||||||
19 | Department by rule. In establishing eligibility standards | ||||||
20 | under this paragraph 11, the Department shall, subject to | ||||||
21 | federal approval: | ||||||
22 | (a) set the income eligibility standard at not | ||||||
23 | lower than 350% of the federal poverty level; | ||||||
24 | (b) exempt retirement accounts that the person | ||||||
25 | cannot access without penalty before the age
of 59 1/2, | ||||||
26 | and medical savings accounts established pursuant to |
| |||||||
| |||||||
1 | 26 U.S.C. 220; | ||||||
2 | (c) allow non-exempt assets up to $25,000 as to | ||||||
3 | those assets accumulated during periods of eligibility | ||||||
4 | under this paragraph 11; and
| ||||||
5 | (d) continue to apply subparagraphs (b) and (c) in | ||||||
6 | determining the eligibility of the person under this | ||||||
7 | Article even if the person loses eligibility under this | ||||||
8 | paragraph 11.
| ||||||
9 | 12. Subject to federal approval, persons who are | ||||||
10 | eligible for medical
assistance coverage under applicable | ||||||
11 | provisions of the federal Social Security
Act and the | ||||||
12 | federal Breast and Cervical Cancer Prevention and | ||||||
13 | Treatment Act of
2000. Those eligible persons are defined | ||||||
14 | to include, but not be limited to,
the following persons:
| ||||||
15 | (1) persons who have been screened for breast or | ||||||
16 | cervical cancer under
the U.S. Centers for Disease | ||||||
17 | Control and Prevention Breast and Cervical Cancer
| ||||||
18 | Program established under Title XV of the federal | ||||||
19 | Public Health Services Act in
accordance with the | ||||||
20 | requirements of Section 1504 of that Act as | ||||||
21 | administered by
the Illinois Department of Public | ||||||
22 | Health; and
| ||||||
23 | (2) persons whose screenings under the above | ||||||
24 | program were funded in whole
or in part by funds | ||||||
25 | appropriated to the Illinois Department of Public | ||||||
26 | Health
for breast or cervical cancer screening.
|
| |||||||
| |||||||
1 | "Medical assistance" under this paragraph 12 shall be | ||||||
2 | identical to the benefits
provided under the State's | ||||||
3 | approved plan under Title XIX of the Social Security
Act. | ||||||
4 | The Department must request federal approval of the | ||||||
5 | coverage under this
paragraph 12 within 30 days after the | ||||||
6 | effective date of this amendatory Act of
the 92nd General | ||||||
7 | Assembly.
| ||||||
8 | In addition to the persons who are eligible for medical | ||||||
9 | assistance pursuant to subparagraphs (1) and (2) of this | ||||||
10 | paragraph 12, and to be paid from funds appropriated to the | ||||||
11 | Department for its medical programs, any uninsured person | ||||||
12 | as defined by the Department in rules residing in Illinois | ||||||
13 | who is younger than 65 years of age, who has been screened | ||||||
14 | for breast and cervical cancer in accordance with standards | ||||||
15 | and procedures adopted by the Department of Public Health | ||||||
16 | for screening, and who is referred to the Department by the | ||||||
17 | Department of Public Health as being in need of treatment | ||||||
18 | for breast or cervical cancer is eligible for medical | ||||||
19 | assistance benefits that are consistent with the benefits | ||||||
20 | provided to those persons described in subparagraphs (1) | ||||||
21 | and (2). Medical assistance coverage for the persons who | ||||||
22 | are eligible under the preceding sentence is not dependent | ||||||
23 | on federal approval, but federal moneys may be used to pay | ||||||
24 | for services provided under that coverage upon federal | ||||||
25 | approval. | ||||||
26 | 13. Subject to appropriation and to federal approval, |
| |||||||
| |||||||
1 | persons living with HIV/AIDS who are not otherwise eligible | ||||||
2 | under this Article and who qualify for services covered | ||||||
3 | under Section 5-5.04 as provided by the Illinois Department | ||||||
4 | by rule.
| ||||||
5 | 14. Subject to the availability of funds for this | ||||||
6 | purpose, the Department may provide coverage under this | ||||||
7 | Article to persons who reside in Illinois who are not | ||||||
8 | eligible under any of the preceding paragraphs and who meet | ||||||
9 | the income guidelines of paragraph 2(a) of this Section and | ||||||
10 | (i) have an application for asylum pending before the | ||||||
11 | federal Department of Homeland Security or on appeal before | ||||||
12 | a court of competent jurisdiction and are represented | ||||||
13 | either by counsel or by an advocate accredited by the | ||||||
14 | federal Department of Homeland Security and employed by a | ||||||
15 | not-for-profit organization in regard to that application | ||||||
16 | or appeal, or (ii) are receiving services through a | ||||||
17 | federally funded torture treatment center. Medical | ||||||
18 | coverage under this paragraph 14 may be provided for up to | ||||||
19 | 24 continuous months from the initial eligibility date so | ||||||
20 | long as an individual continues to satisfy the criteria of | ||||||
21 | this paragraph 14. If an individual has an appeal pending | ||||||
22 | regarding an application for asylum before the Department | ||||||
23 | of Homeland Security, eligibility under this paragraph 14 | ||||||
24 | may be extended until a final decision is rendered on the | ||||||
25 | appeal. The Department may adopt rules governing the | ||||||
26 | implementation of this paragraph 14.
|
| |||||||
| |||||||
1 | 15. Family Care Eligibility. | ||||||
2 | (a) Through December 31, 2013, a A caretaker | ||||||
3 | relative who is 19 years of age or older when countable | ||||||
4 | income is at or below 185% of the Federal Poverty Level | ||||||
5 | Guidelines, as published annually in the Federal | ||||||
6 | Register, for the appropriate family size. Beginning | ||||||
7 | January 1, 2014, a caretaker relative who is 19 years | ||||||
8 | of age or older when countable income is at or below | ||||||
9 | 133% of the Federal Poverty Level Guidelines, as | ||||||
10 | published annually in the Federal Register, for the | ||||||
11 | appropriate family size. A person may not spend down to | ||||||
12 | become eligible under this paragraph 15. | ||||||
13 | (b) Eligibility shall be reviewed annually. | ||||||
14 | (c) Caretaker relatives enrolled under this | ||||||
15 | paragraph 15 in families with countable income above | ||||||
16 | 150% and at or below 185% of the Federal Poverty Level | ||||||
17 | Guidelines shall be counted as family members and pay | ||||||
18 | premiums as established under the Children's Health | ||||||
19 | Insurance Program Act. | ||||||
20 | (d) Premiums shall be billed by and payable to the | ||||||
21 | Department or its authorized agent, on a monthly basis. | ||||||
22 | (e) The premium due date is the last day of the | ||||||
23 | month preceding the month of coverage. | ||||||
24 | (f) Individuals shall have a grace period through | ||||||
25 | 30 days of coverage to pay the premium. | ||||||
26 | (g) Failure to pay the full monthly premium by the |
| |||||||
| |||||||
1 | last day of the grace period shall result in | ||||||
2 | termination of coverage. | ||||||
3 | (h) Partial premium payments shall not be | ||||||
4 | refunded. | ||||||
5 | (i) Following termination of an individual's | ||||||
6 | coverage under this paragraph 15, the following action | ||||||
7 | is required before the individual can be re-enrolled: | ||||||
8 | (1) A new application must be completed and the | ||||||
9 | individual must be determined otherwise eligible. | ||||||
10 | (2) There must be full payment of premiums due | ||||||
11 | under this Code, the Children's Health Insurance | ||||||
12 | Program Act, the Covering ALL KIDS Health | ||||||
13 | Insurance Act, or any other healthcare program | ||||||
14 | administered by the Department for periods in | ||||||
15 | which a premium was owed and not paid for the | ||||||
16 | individual. | ||||||
17 | (3) The first month's premium must be paid if | ||||||
18 | there was an unpaid premium on the date the | ||||||
19 | individual's previous coverage was canceled. | ||||||
20 | The Department is authorized to implement the | ||||||
21 | provisions of this amendatory Act of the 95th General | ||||||
22 | Assembly by adopting the medical assistance rules in effect | ||||||
23 | as of October 1, 2007, at 89 Ill. Admin. Code 125, and at | ||||||
24 | 89 Ill. Admin. Code 120.32 along with only those changes | ||||||
25 | necessary to conform to federal Medicaid requirements, | ||||||
26 | federal laws, and federal regulations, including but not |
| |||||||
| |||||||
1 | limited to Section 1931 of the Social Security Act (42 | ||||||
2 | U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department | ||||||
3 | of Health and Human Services, and the countable income | ||||||
4 | eligibility standard authorized by this paragraph 15. The | ||||||
5 | Department may not otherwise adopt any rule to implement | ||||||
6 | this increase except as authorized by law, to meet the | ||||||
7 | eligibility standards authorized by the federal government | ||||||
8 | in the Medicaid State Plan or the Title XXI Plan, or to | ||||||
9 | meet an order from the federal government or any court. | ||||||
10 | 16. Subject to appropriation, uninsured persons who | ||||||
11 | are not otherwise eligible under this Section who have been | ||||||
12 | certified and referred by the Department of Public Health | ||||||
13 | as having been screened and found to need diagnostic | ||||||
14 | evaluation or treatment, or both diagnostic evaluation and | ||||||
15 | treatment, for prostate or testicular cancer. For the | ||||||
16 | purposes of this paragraph 16, uninsured persons are those | ||||||
17 | who do not have creditable coverage, as defined under the | ||||||
18 | Health Insurance Portability and Accountability Act, or | ||||||
19 | have otherwise exhausted any insurance benefits they may | ||||||
20 | have had, for prostate or testicular cancer diagnostic | ||||||
21 | evaluation or treatment, or both diagnostic evaluation and | ||||||
22 | treatment.
To be eligible, a person must furnish a Social | ||||||
23 | Security number.
A person's assets are exempt from | ||||||
24 | consideration in determining eligibility under this | ||||||
25 | paragraph 16.
Such persons shall be eligible for medical | ||||||
26 | assistance under this paragraph 16 for so long as they need |
| |||||||
| |||||||
1 | treatment for the cancer. A person shall be considered to | ||||||
2 | need treatment if, in the opinion of the person's treating | ||||||
3 | physician, the person requires therapy directed toward | ||||||
4 | cure or palliation of prostate or testicular cancer, | ||||||
5 | including recurrent metastatic cancer that is a known or | ||||||
6 | presumed complication of prostate or testicular cancer and | ||||||
7 | complications resulting from the treatment modalities | ||||||
8 | themselves. Persons who require only routine monitoring | ||||||
9 | services are not considered to need treatment.
"Medical | ||||||
10 | assistance" under this paragraph 16 shall be identical to | ||||||
11 | the benefits provided under the State's approved plan under | ||||||
12 | Title XIX of the Social Security Act.
Notwithstanding any | ||||||
13 | other provision of law, the Department (i) does not have a | ||||||
14 | claim against the estate of a deceased recipient of | ||||||
15 | services under this paragraph 16 and (ii) does not have a | ||||||
16 | lien against any homestead property or other legal or | ||||||
17 | equitable real property interest owned by a recipient of | ||||||
18 | services under this paragraph 16. | ||||||
19 | In implementing the provisions of Public Act 96-20, the | ||||||
20 | Department is authorized to adopt only those rules necessary, | ||||||
21 | including emergency rules. Nothing in Public Act 96-20 permits | ||||||
22 | the Department to adopt rules or issue a decision that expands | ||||||
23 | eligibility for the FamilyCare Program to a person whose income | ||||||
24 | exceeds 185% of the Federal Poverty Level as determined from | ||||||
25 | time to time by the U.S. Department of Health and Human | ||||||
26 | Services, unless the Department is provided with express |
| |||||||
| |||||||
1 | statutory authority. | ||||||
2 | The Illinois Department and the Governor shall provide a | ||||||
3 | plan for
coverage of the persons eligible under paragraph 7 as | ||||||
4 | soon as possible after
July 1, 1984.
| ||||||
5 | The eligibility of any such person for medical assistance | ||||||
6 | under this
Article is not affected by the payment of any grant | ||||||
7 | under the Senior
Citizens and Disabled Persons Property Tax | ||||||
8 | Relief and Pharmaceutical
Assistance Act or any distributions | ||||||
9 | or items of income described under
subparagraph (X) of
| ||||||
10 | paragraph (2) of subsection (a) of Section 203 of the Illinois | ||||||
11 | Income Tax
Act. The Department shall by rule establish the | ||||||
12 | amounts of
assets to be disregarded in determining eligibility | ||||||
13 | for medical assistance,
which shall at a minimum equal the | ||||||
14 | amounts to be disregarded under the
Federal Supplemental | ||||||
15 | Security Income Program. The amount of assets of a
single | ||||||
16 | person to be disregarded
shall not be less than $2,000, and the | ||||||
17 | amount of assets of a married couple
to be disregarded shall | ||||||
18 | not be less than $3,000.
| ||||||
19 | To the extent permitted under federal law, any person found | ||||||
20 | guilty of a
second violation of Article VIIIA
shall be | ||||||
21 | ineligible for medical assistance under this Article, as | ||||||
22 | provided
in Section 8A-8.
| ||||||
23 | The eligibility of any person for medical assistance under | ||||||
24 | this Article
shall not be affected by the receipt by the person | ||||||
25 | of donations or benefits
from fundraisers held for the person | ||||||
26 | in cases of serious illness,
as long as neither the person nor |
| |||||||
| |||||||
1 | members of the person's family
have actual control over the | ||||||
2 | donations or benefits or the disbursement
of the donations or | ||||||
3 | benefits.
| ||||||
4 | (Source: P.A. 95-546, eff. 8-29-07; 95-1055, eff. 4-10-09; | ||||||
5 | 96-20, eff. 6-30-09; 96-181, eff. 8-10-09; 96-328, eff. | ||||||
6 | 8-11-09; 96-567, eff. 1-1-10; 96-1000, eff. 7-2-10; 96-1123, | ||||||
7 | eff. 1-1-11; 96-1270, eff. 7-26-10; revised 9-16-10.)
| ||||||
8 | (305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
| ||||||
9 | Sec. 5-4.1. Co-payments. The Department may by rule provide | ||||||
10 | that recipients
under any Article of this Code shall pay a fee | ||||||
11 | as a co-payment for services.
Co-payments shall be maximized to | ||||||
12 | the extent permitted by federal law. Provided, however, that | ||||||
13 | any such rule must provide that no
co-payment requirement can | ||||||
14 | exist
for renal dialysis, radiation therapy, cancer | ||||||
15 | chemotherapy, or insulin, and
other products necessary on a | ||||||
16 | recurring basis, the absence of which would
be life | ||||||
17 | threatening, or where co-payment expenditures for required | ||||||
18 | services
and/or medications for chronic diseases that the | ||||||
19 | Illinois Department shall
by rule designate shall cause an | ||||||
20 | extensive financial burden on the
recipient, and provided no | ||||||
21 | co-payment shall exist for emergency room
encounters which are | ||||||
22 | for medical emergencies. The Department shall seek approval of | ||||||
23 | a State plan amendment that allows pharmacies to refuse to | ||||||
24 | dispense drugs in circumstances where the recipient does not | ||||||
25 | pay the required co-payment. In the event the State plan |
| |||||||
| |||||||
1 | amendment is rejected, co-payments may not exceed $3 for brand | ||||||
2 | name drugs, $1 for other pharmacy
services other than for | ||||||
3 | generic drugs, and $2 for physician services, dental
services, | ||||||
4 | optical services and supplies, chiropractic services, podiatry
| ||||||
5 | services, and encounter rate clinic services. There shall be no | ||||||
6 | co-payment for
generic drugs. Co-payments may not exceed $10 | ||||||
7 | for emergency room use for a non-emergency situation as defined | ||||||
8 | by the Department by rule and subject to federal approval. | ||||||
9 | Co-payments may not exceed $3 for hospital outpatient and | ||||||
10 | clinic
services.
| ||||||
11 | (Source: P.A. 96-1501, eff. 1-25-11.)
| ||||||
12 | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
| ||||||
13 | Sec. 5-5.12. Pharmacy payments.
| ||||||
14 | (a) Every request submitted by a pharmacy for reimbursement | ||||||
15 | under this
Article for prescription drugs provided to a | ||||||
16 | recipient of aid under this
Article shall include the name of | ||||||
17 | the prescriber or an acceptable
identification number as | ||||||
18 | established by the Department.
| ||||||
19 | (b) Pharmacies providing prescription drugs under
this | ||||||
20 | Article shall be reimbursed at a rate which shall include
a | ||||||
21 | professional dispensing fee as determined by the Illinois
| ||||||
22 | Department, plus the current acquisition cost of the | ||||||
23 | prescription
drug dispensed. The Illinois Department shall | ||||||
24 | update its
information on the acquisition costs of all | ||||||
25 | prescription drugs
no less frequently than every 30 days. |
| |||||||
| |||||||
1 | However, the Illinois
Department may set the rate of | ||||||
2 | reimbursement for the acquisition
cost, by rule, at a | ||||||
3 | percentage of the current average wholesale
acquisition cost.
| ||||||
4 | (c) (Blank).
| ||||||
5 | (d) The Department shall not impose requirements for prior | ||||||
6 | approval
based on a preferred drug list for anti-retroviral, | ||||||
7 | anti-hemophilic factor
concentrates,
or
any atypical | ||||||
8 | antipsychotics, conventional antipsychotics,
or | ||||||
9 | anticonvulsants used for the treatment of serious mental
| ||||||
10 | illnesses
until 30 days after it has conducted a study of the | ||||||
11 | impact of such
requirements on patient care and submitted a | ||||||
12 | report to the Speaker of the
House of Representatives and the | ||||||
13 | President of the Senate. The Department shall review | ||||||
14 | utilization of narcotic medications in the medical assistance | ||||||
15 | program and impose utilization controls that protect against | ||||||
16 | abuse.
| ||||||
17 | (e) When making determinations as to which drugs shall be | ||||||
18 | on a prior approval list, the Department shall include as part | ||||||
19 | of the analysis for this determination, the degree to which a | ||||||
20 | drug may affect individuals in different ways based on factors | ||||||
21 | including the gender of the person taking the medication. | ||||||
22 | (f) The Department shall cooperate with the Department of | ||||||
23 | Public Health and the Department of Human Services Division of | ||||||
24 | Mental Health in identifying psychotropic medications that, | ||||||
25 | when given in a particular form, manner, duration, or frequency | ||||||
26 | (including "as needed") in a dosage, or in conjunction with |
| |||||||
| |||||||
1 | other psychotropic medications to a nursing home resident, may | ||||||
2 | constitute a chemical restraint or an "unnecessary drug" as | ||||||
3 | defined by the Nursing Home Care Act or Titles XVIII and XIX of | ||||||
4 | the Social Security Act and the implementing rules and | ||||||
5 | regulations. The Department shall require prior approval for | ||||||
6 | any such medication prescribed for a nursing home resident that | ||||||
7 | appears to be a chemical restraint or an unnecessary drug. The | ||||||
8 | Department shall consult with the Department of Human Services | ||||||
9 | Division of Mental Health in developing a protocol and criteria | ||||||
10 | for deciding whether to grant such prior approval. | ||||||
11 | (g) The Department may by rule provide for reimbursement of | ||||||
12 | the dispensing of a 90-day supply of a generic, non-narcotic | ||||||
13 | maintenance medication in circumstances where it is cost | ||||||
14 | effective. | ||||||
15 | (h) Effective July 1, 2011, the Department shall | ||||||
16 | discontinue coverage of select over-the-counter drugs, | ||||||
17 | including analgesics and cough and cold and allergy | ||||||
18 | medications. | ||||||
19 | (i) The Department shall seek any necessary waiver from the | ||||||
20 | federal government in order to establish a program limiting the | ||||||
21 | pharmacies eligible to dispense specialty drugs and shall issue | ||||||
22 | a Request for Proposals in order to maximize savings on these | ||||||
23 | drugs. The Department shall by rule establish the drugs | ||||||
24 | required to be dispensed in this program. | ||||||
25 | (Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10; | ||||||
26 | 96-1501, eff. 1-25-11.)
|
| |||||||
| |||||||
1 | (305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)
| ||||||
2 | Sec. 5A-10. Applicability.
| ||||||
3 | (a) The assessment imposed by Section 5A-2 shall not take | ||||||
4 | effect or shall
cease to be imposed, and
any moneys
remaining | ||||||
5 | in the Fund shall be refunded to hospital providers
in | ||||||
6 | proportion to the amounts paid by them, if:
| ||||||
7 | (1) The sum of the appropriations for State fiscal | ||||||
8 | years 2004 and 2005
from the
General Revenue Fund for | ||||||
9 | hospital payments
under the medical assistance program is | ||||||
10 | less than $4,500,000,000 or the appropriation for each of | ||||||
11 | State fiscal years 2006, 2007 and 2008 from the General | ||||||
12 | Revenue Fund for hospital payments under the medical | ||||||
13 | assistance program is less than $2,500,000,000 increased | ||||||
14 | annually to reflect any increase in the number of | ||||||
15 | recipients, or the annual appropriation for State fiscal | ||||||
16 | years 2009 , 2010, 2011, 2013, and 2014 through 2014 , from | ||||||
17 | the General Revenue Fund combined with the Hospital | ||||||
18 | Provider Fund as authorized in Section 5A-8 for hospital | ||||||
19 | payments under the medical assistance program, is less than | ||||||
20 | the amount appropriated for State fiscal year 2009, | ||||||
21 | adjusted annually to reflect any change in the number of | ||||||
22 | recipients, excluding State fiscal year 2009 supplemental | ||||||
23 | appropriations made necessary by the enactment of the | ||||||
24 | American Recovery and Reinvestment Act of 2009; or
| ||||||
25 | (2) For State fiscal years prior to State fiscal year |
| |||||||
| |||||||
1 | 2009, the Department of Healthcare and Family Services | ||||||
2 | (formerly Department of Public Aid) makes changes in its | ||||||
3 | rules
that
reduce the hospital inpatient or outpatient | ||||||
4 | payment rates, including adjustment
payment rates, in | ||||||
5 | effect on October 1, 2004, except for hospitals described | ||||||
6 | in
subsection (b) of Section 5A-3 and except for changes in | ||||||
7 | the methodology for calculating outlier payments to | ||||||
8 | hospitals for exceptionally costly stays, so long as those | ||||||
9 | changes do not reduce aggregate
expenditures below the | ||||||
10 | amount expended in State fiscal year 2005 for such
| ||||||
11 | services; or
| ||||||
12 | (2.1) For State fiscal years 2009 through 2014, the
| ||||||
13 | Department of Healthcare and Family Services adopts any | ||||||
14 | administrative rule change to reduce payment rates or | ||||||
15 | alters any payment methodology that reduces any payment | ||||||
16 | rates made to operating hospitals under the approved Title | ||||||
17 | XIX or Title XXI State plan in effect January 1, 2008 | ||||||
18 | except for: | ||||||
19 | (A) any changes for hospitals described in | ||||||
20 | subsection (b) of Section 5A-3; or | ||||||
21 | (B) any rates for payments made under this Article | ||||||
22 | V-A; or | ||||||
23 | (C) any changes proposed in State plan amendment | ||||||
24 | transmittal numbers 08-01, 08-02, 08-04, 08-06, and | ||||||
25 | 08-07; or | ||||||
26 | (D) in relation to any admissions on or after |
| |||||||
| |||||||
1 | January 1, 2011, a modification in the methodology for | ||||||
2 | calculating outlier payments to hospitals for | ||||||
3 | exceptionally costly stays, for hospitals reimbursed | ||||||
4 | under the diagnosis-related grouping methodology; | ||||||
5 | provided that the Department shall be limited to one | ||||||
6 | such modification during the 36-month period after the | ||||||
7 | effective date of this amendatory Act of the 96th | ||||||
8 | General Assembly; or | ||||||
9 | (3) The payments to hospitals required under Section | ||||||
10 | 5A-12 or Section 5A-12.2 are changed or
are
not eligible | ||||||
11 | for federal matching funds under Title XIX or XXI of the | ||||||
12 | Social
Security Act.
| ||||||
13 | (b) The assessment imposed by Section 5A-2 shall not take | ||||||
14 | effect or
shall
cease to be imposed if the assessment is | ||||||
15 | determined to be an impermissible
tax under Title XIX
of the | ||||||
16 | Social Security Act. Moneys in the Hospital Provider Fund | ||||||
17 | derived
from assessments imposed prior thereto shall be
| ||||||
18 | disbursed in accordance with Section 5A-8 to the extent federal | ||||||
19 | financial participation is
not reduced due to the | ||||||
20 | impermissibility of the assessments, and any
remaining
moneys | ||||||
21 | shall be
refunded to hospital providers in proportion to the | ||||||
22 | amounts paid by them.
| ||||||
23 | (Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08; 96-8, | ||||||
24 | eff. 4-28-09; 96-1530, eff. 2-16-11.)
| ||||||
25 | Section 20. The Senior Citizens and Disabled Persons |
| |||||||
| |||||||
1 | Property Tax Relief and Pharmaceutical Assistance Act is | ||||||
2 | amended by changing Section 4 as follows:
| ||||||
3 | (320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
| ||||||
4 | Sec. 4. Amount of Grant.
| ||||||
5 | (a) In general. Any individual 65 years or older or any | ||||||
6 | individual who will
become 65 years old during the calendar | ||||||
7 | year in which a claim is filed, and any
surviving spouse of | ||||||
8 | such a claimant, who at the time of death received or was
| ||||||
9 | entitled to receive a grant pursuant to this Section, which | ||||||
10 | surviving spouse
will become 65 years of age within the 24 | ||||||
11 | months immediately following the
death of such claimant and | ||||||
12 | which surviving spouse but for his or her age is
otherwise | ||||||
13 | qualified to receive a grant pursuant to this Section, and any
| ||||||
14 | disabled person whose annual household income is less than the | ||||||
15 | income eligibility limitation, as defined in subsection (a-5)
| ||||||
16 | and whose household is liable for payment of property taxes | ||||||
17 | accrued or has
paid rent constituting property taxes accrued | ||||||
18 | and is domiciled in this State
at the time he or she files his | ||||||
19 | or her claim is entitled to claim a
grant under this Act.
With | ||||||
20 | respect to claims filed by individuals who will become 65 years | ||||||
21 | old
during the calendar year in which a claim is filed, the | ||||||
22 | amount of any grant
to which that household is entitled shall | ||||||
23 | be an amount equal to 1/12 of the
amount to which the claimant | ||||||
24 | would otherwise be entitled as provided in
this Section, | ||||||
25 | multiplied by the number of months in which the claimant was
65 |
| |||||||
| |||||||
1 | in the calendar year in which the claim is filed.
| ||||||
2 | (a-5) Income eligibility limitation. For purposes of this | ||||||
3 | Section, "income eligibility limitation" means an amount for | ||||||
4 | grant years 2008 and thereafter: | ||||||
5 | (1) less than $22,218 for a household containing one | ||||||
6 | person; | ||||||
7 | (2) less than $29,480 for a household containing 2 | ||||||
8 | persons; or | ||||||
9 | (3) less than $36,740 for a
household containing 3 or | ||||||
10 | more persons. | ||||||
11 | For 2009 claim year applications submitted during calendar | ||||||
12 | year 2010, a household must have annual household income of | ||||||
13 | less than $27,610 for a household containing one person; less | ||||||
14 | than $36,635 for a household containing 2 persons; or less than | ||||||
15 | $45,657 for a household containing 3 or more persons. | ||||||
16 | The Department on Aging may adopt rules such that on | ||||||
17 | January 1, 2011, and thereafter, the foregoing household income | ||||||
18 | eligibility limits may be changed to reflect the annual cost of | ||||||
19 | living adjustment in Social Security and Supplemental Security | ||||||
20 | Income benefits that are applicable to the year for which those | ||||||
21 | benefits are being reported as income on an application. | ||||||
22 | If a person files as a surviving spouse, then only his or | ||||||
23 | her income shall be counted in determining his or her household | ||||||
24 | income. | ||||||
25 | (b) Limitation. Except as otherwise provided in | ||||||
26 | subsections (a) and (f)
of this Section, the maximum amount of |
| |||||||
| |||||||
1 | grant which a claimant is
entitled to claim is the amount by | ||||||
2 | which the property taxes accrued which
were paid or payable | ||||||
3 | during the last preceding tax year or rent
constituting | ||||||
4 | property taxes accrued upon the claimant's residence for the
| ||||||
5 | last preceding taxable year exceeds 3 1/2% of the claimant's | ||||||
6 | household
income for that year but in no event is the grant to | ||||||
7 | exceed (i) $700 less
4.5% of household income for that year for | ||||||
8 | those with a household income of
$14,000 or less or (ii) $70 if | ||||||
9 | household income for that year is more than
$14,000.
| ||||||
10 | (c) Public aid recipients. If household income in one or | ||||||
11 | more
months during a year includes cash assistance in excess of | ||||||
12 | $55 per month
from the Department of Healthcare and Family | ||||||
13 | Services or the Department of Human Services (acting
as | ||||||
14 | successor to the Department of Public Aid under the Department | ||||||
15 | of Human
Services Act) which was determined under regulations | ||||||
16 | of
that Department on a measure of need that included an | ||||||
17 | allowance for actual
rent or property taxes paid by the | ||||||
18 | recipient of that assistance, the amount
of grant to which that | ||||||
19 | household is entitled, except as otherwise provided in
| ||||||
20 | subsection (a), shall be the product of (1) the maximum amount | ||||||
21 | computed as
specified in subsection (b) of this Section and (2) | ||||||
22 | the ratio of the number of
months in which household income did | ||||||
23 | not include such cash assistance over $55
to the number twelve. | ||||||
24 | If household income did not include such cash assistance
over | ||||||
25 | $55 for any months during the year, the amount of the grant to | ||||||
26 | which the
household is entitled shall be the maximum amount |
| |||||||
| |||||||
1 | computed as specified in
subsection (b) of this Section. For | ||||||
2 | purposes of this paragraph (c), "cash
assistance" does not | ||||||
3 | include any amount received under the federal Supplemental
| ||||||
4 | Security Income (SSI) program.
| ||||||
5 | (d) Joint ownership. If title to the residence is held | ||||||
6 | jointly by
the claimant with a person who is not a member of | ||||||
7 | his or her household,
the amount of property taxes accrued used | ||||||
8 | in computing the amount of grant
to which he or she is entitled | ||||||
9 | shall be the same percentage of property
taxes accrued as is | ||||||
10 | the percentage of ownership held by the claimant in the
| ||||||
11 | residence.
| ||||||
12 | (e) More than one residence. If a claimant has occupied | ||||||
13 | more than
one residence in the taxable year, he or she may | ||||||
14 | claim only one residence
for any part of a month. In the case | ||||||
15 | of property taxes accrued, he or she
shall prorate 1/12 of the | ||||||
16 | total property taxes accrued on
his or her residence to each | ||||||
17 | month that he or she owned and occupied
that residence; and, in | ||||||
18 | the case of rent constituting property taxes accrued,
shall | ||||||
19 | prorate each month's rent payments to the residence
actually | ||||||
20 | occupied during that month.
| ||||||
21 | (f) (Blank).
| ||||||
22 | (g) Effective January 1, 2006, there is hereby established | ||||||
23 | a program of pharmaceutical assistance to the aged and | ||||||
24 | disabled, entitled the Illinois Seniors and Disabled Drug | ||||||
25 | Coverage Program, which shall be administered by the Department | ||||||
26 | of Healthcare and Family Services and the Department on Aging |
| |||||||
| |||||||
1 | in accordance with this subsection, to consist of coverage of | ||||||
2 | specified prescription drugs on behalf of beneficiaries of the | ||||||
3 | program as set forth in this subsection. | ||||||
4 | To become a beneficiary under the program established under | ||||||
5 | this subsection, a person must: | ||||||
6 | (1) be (i) 65 years of age or older or (ii) disabled; | ||||||
7 | and | ||||||
8 | (2) be domiciled in this State; and | ||||||
9 | (3) enroll with a qualified Medicare Part D | ||||||
10 | Prescription Drug Plan if eligible and apply for all | ||||||
11 | available subsidies under Medicare Part D; and | ||||||
12 | (4) for the 2006 and 2007 claim years, have a maximum | ||||||
13 | household income of (i) less than $21,218 for a household | ||||||
14 | containing one person, (ii) less than $28,480 for a | ||||||
15 | household containing 2 persons, or (iii) less than $35,740 | ||||||
16 | for a household containing 3 or more persons; and | ||||||
17 | (5) for the 2008 claim year, have a maximum household | ||||||
18 | income of (i) less than $22,218 for a household containing | ||||||
19 | one person, (ii) $29,480 for a household containing 2 | ||||||
20 | persons, or (iii) $36,740 for a household containing 3 or | ||||||
21 | more persons; and | ||||||
22 | (6) for 2009 claim year applications submitted during | ||||||
23 | calendar year 2010, have annual household income of less | ||||||
24 | than (i) $27,610 for a household containing one person; | ||||||
25 | (ii) less than $36,635 for a household containing 2 | ||||||
26 | persons; or (iii) less than $45,657 for a household |
| |||||||
| |||||||
1 | containing 3 or more persons ; and . | ||||||
2 | (7) as of September 1, 2011, have a maximum household | ||||||
3 | income at or below 200% of the federal poverty level. | ||||||
4 | The Department of Healthcare and Family Services may adopt | ||||||
5 | rules such that on January 1, 2011, and thereafter, the | ||||||
6 | foregoing household income eligibility limits may be changed to | ||||||
7 | reflect the annual cost of living adjustment in Social Security | ||||||
8 | and Supplemental Security Income benefits that are applicable | ||||||
9 | to the year for which those benefits are being reported as | ||||||
10 | income on an application. | ||||||
11 | All individuals enrolled as of December 31, 2005, in the | ||||||
12 | pharmaceutical assistance program operated pursuant to | ||||||
13 | subsection (f) of this Section and all individuals enrolled as | ||||||
14 | of December 31, 2005, in the SeniorCare Medicaid waiver program | ||||||
15 | operated pursuant to Section 5-5.12a of the Illinois Public Aid | ||||||
16 | Code shall be automatically enrolled in the program established | ||||||
17 | by this subsection for the first year of operation without the | ||||||
18 | need for further application, except that they must apply for | ||||||
19 | Medicare Part D and the Low Income Subsidy under Medicare Part | ||||||
20 | D. A person enrolled in the pharmaceutical assistance program | ||||||
21 | operated pursuant to subsection (f) of this Section as of | ||||||
22 | December 31, 2005, shall not lose eligibility in future years | ||||||
23 | due only to the fact that they have not reached the age of 65. | ||||||
24 | To the extent permitted by federal law, the Department may | ||||||
25 | act as an authorized representative of a beneficiary in order | ||||||
26 | to enroll the beneficiary in a Medicare Part D Prescription |
| |||||||
| |||||||
1 | Drug Plan if the beneficiary has failed to choose a plan and, | ||||||
2 | where possible, to enroll beneficiaries in the low-income | ||||||
3 | subsidy program under Medicare Part D or assist them in | ||||||
4 | enrolling in that program. | ||||||
5 | Beneficiaries under the program established under this | ||||||
6 | subsection shall be divided into the following 4 eligibility | ||||||
7 | groups: | ||||||
8 | (A) Eligibility Group 1 shall consist of beneficiaries | ||||||
9 | who are not eligible for Medicare Part D coverage and who
| ||||||
10 | are: | ||||||
11 | (i) disabled and under age 65; or | ||||||
12 | (ii) age 65 or older, with incomes over 200% of the | ||||||
13 | Federal Poverty Level; or | ||||||
14 | (iii) age 65 or older, with incomes at or below | ||||||
15 | 200% of the Federal Poverty Level and not eligible for | ||||||
16 | federally funded means-tested benefits due to | ||||||
17 | immigration status. | ||||||
18 | (B) Eligibility Group 2 shall consist of beneficiaries | ||||||
19 | who are eligible for Medicare Part D coverage. | ||||||
20 | (C) Eligibility Group 3 shall consist of beneficiaries | ||||||
21 | age 65 or older, with incomes at or below 200% of the | ||||||
22 | Federal Poverty Level, who are not barred from receiving | ||||||
23 | federally funded means-tested benefits due to immigration | ||||||
24 | status and are not eligible for Medicare Part D coverage. | ||||||
25 | If the State applies and receives federal approval for | ||||||
26 | a waiver under Title XIX of the Social Security Act, |
| |||||||
| |||||||
1 | persons in Eligibility Group 3 shall continue to receive | ||||||
2 | benefits through the approved waiver, and Eligibility | ||||||
3 | Group 3 may be expanded to include disabled persons under | ||||||
4 | age 65 with incomes under 200% of the Federal Poverty Level | ||||||
5 | who are not eligible for Medicare and who are not barred | ||||||
6 | from receiving federally funded means-tested benefits due | ||||||
7 | to immigration status. | ||||||
8 | (D) Eligibility Group 4 shall consist of beneficiaries | ||||||
9 | who are otherwise described in Eligibility Group 2 who have | ||||||
10 | a diagnosis of HIV or AIDS.
| ||||||
11 | The program established under this subsection shall cover | ||||||
12 | the cost of covered prescription drugs in excess of the | ||||||
13 | beneficiary cost-sharing amounts set forth in this paragraph | ||||||
14 | that are not covered by Medicare. The Department of Healthcare | ||||||
15 | and Family Services may establish by emergency rule changes in | ||||||
16 | cost-sharing necessary to conform the cost of the program to | ||||||
17 | the amounts appropriated for State fiscal year 2012 and future | ||||||
18 | fiscal years except that the 24-month limitation on the | ||||||
19 | adoption of emergency rules and the provisions of Sections | ||||||
20 | 5-115 and 5-125 of the Illinois Administrative Procedure Act | ||||||
21 | shall not apply to rules adopted under this subsection (g). The | ||||||
22 | adoption of emergency rules authorized by this subsection (g) | ||||||
23 | shall be deemed to be necessary for the public interest, | ||||||
24 | safety, and welfare. In 2006, beneficiaries shall pay a | ||||||
25 | co-payment of $2 for each prescription of a generic drug and $5 | ||||||
26 | for each prescription of a brand-name drug. In future years, |
| |||||||
| |||||||
1 | beneficiaries shall pay co-payments equal to the co-payments | ||||||
2 | required under Medicare Part D for "other low-income subsidy | ||||||
3 | eligible individuals" pursuant to 42 CFR 423.782(b). For | ||||||
4 | individuals in Eligibility Groups 1, 2, and 3, once the program | ||||||
5 | established under this subsection and Medicare combined have | ||||||
6 | paid $1,750 in a year for covered prescription drugs, the | ||||||
7 | beneficiary shall pay 20% of the cost of each prescription in | ||||||
8 | addition to the co-payments set forth in this paragraph. For | ||||||
9 | individuals in Eligibility Group 4, once the program | ||||||
10 | established under this subsection and Medicare combined have | ||||||
11 | paid $1,750 in a year for covered prescription drugs, the | ||||||
12 | beneficiary shall pay 20% of the cost of each prescription in | ||||||
13 | addition to the co-payments set forth in this paragraph unless | ||||||
14 | the drug is included in the formulary of the Illinois AIDS Drug | ||||||
15 | Assistance Program operated by the Illinois Department of | ||||||
16 | Public Health and covered by the Medicare Part D Prescription | ||||||
17 | Drug Plan in which the beneficiary is enrolled. If the drug is | ||||||
18 | included in the formulary of the Illinois AIDS Drug Assistance | ||||||
19 | Program and covered by the Medicare Part D Prescription Drug | ||||||
20 | Plan in which the beneficiary is enrolled, individuals in | ||||||
21 | Eligibility Group 4 shall continue to pay the co-payments set | ||||||
22 | forth in this paragraph after the program established under | ||||||
23 | this subsection and Medicare combined have paid $1,750 in a | ||||||
24 | year for covered prescription drugs.
| ||||||
25 | For beneficiaries eligible for Medicare Part D coverage, | ||||||
26 | the program established under this subsection shall pay 100% of |
| |||||||
| |||||||
1 | the premiums charged by a qualified Medicare Part D | ||||||
2 | Prescription Drug Plan for Medicare Part D basic prescription | ||||||
3 | drug coverage, not including any late enrollment penalties. | ||||||
4 | Qualified Medicare Part D Prescription Drug Plans may be | ||||||
5 | limited by the Department of Healthcare and Family Services to | ||||||
6 | those plans that sign a coordination agreement with the | ||||||
7 | Department. | ||||||
8 | For Notwithstanding Section 3.15, for purposes of the | ||||||
9 | program established under this subsection, the term "covered | ||||||
10 | prescription drug" has the following meanings: | ||||||
11 | For Eligibility Group 1, "covered prescription drug" | ||||||
12 | means: (1) any cardiovascular agent or drug; (2) any | ||||||
13 | insulin or other prescription drug used in the treatment of | ||||||
14 | diabetes, including syringe and needles used to administer | ||||||
15 | the insulin; (3) any prescription drug used in the | ||||||
16 | treatment of arthritis; (4) any prescription drug used in | ||||||
17 | the treatment of cancer; (5) any prescription drug used in | ||||||
18 | the treatment of Alzheimer's disease; (6) any prescription | ||||||
19 | drug used in the treatment of Parkinson's disease; (7) any | ||||||
20 | prescription drug used in the treatment of glaucoma; (8) | ||||||
21 | any prescription drug used in the treatment of lung disease | ||||||
22 | and smoking-related illnesses; (9) any prescription drug | ||||||
23 | used in the treatment of osteoporosis; and (10) any | ||||||
24 | prescription drug used in the treatment of multiple | ||||||
25 | sclerosis. The Department may add additional therapeutic | ||||||
26 | classes by rule. The Department may adopt a preferred drug |
| |||||||
| |||||||
1 | list within any of the classes of drugs described in items | ||||||
2 | (1) through (10) of this paragraph. The specific drugs or | ||||||
3 | therapeutic classes of covered prescription drugs shall be | ||||||
4 | indicated by rule. | ||||||
5 | For Eligibility Group 2, "covered prescription drug" | ||||||
6 | means those drugs covered by the Medicare Part D | ||||||
7 | Prescription Drug Plan in which the beneficiary is | ||||||
8 | enrolled. | ||||||
9 | For Eligibility Group 3, "covered prescription drug" | ||||||
10 | means those drugs covered by the Medical Assistance Program | ||||||
11 | under Article V of the Illinois Public Aid Code. | ||||||
12 | For Eligibility Group 4, "covered prescription drug" | ||||||
13 | means those drugs covered by the Medicare Part D | ||||||
14 | Prescription Drug Plan in which the beneficiary is | ||||||
15 | enrolled. | ||||||
16 | An individual in Eligibility Group 1, 2, 3, or 4 may opt to | ||||||
17 | receive a $25 monthly payment in lieu of the direct coverage | ||||||
18 | described in this subsection. | ||||||
19 | Any person otherwise eligible for pharmaceutical | ||||||
20 | assistance under this subsection whose covered drugs are | ||||||
21 | covered by any public program is ineligible for assistance | ||||||
22 | under this subsection to the extent that the cost of those | ||||||
23 | drugs is covered by the other program. | ||||||
24 | The Department of Healthcare and Family Services shall | ||||||
25 | establish by rule the methods by which it will provide for the | ||||||
26 | coverage called for in this subsection. Those methods may |
| |||||||
| |||||||
1 | include direct reimbursement to pharmacies or the payment of a | ||||||
2 | capitated amount to Medicare Part D Prescription Drug Plans. | ||||||
3 | For a pharmacy to be reimbursed under the program | ||||||
4 | established under this subsection, it must comply with rules | ||||||
5 | adopted by the Department of Healthcare and Family Services | ||||||
6 | regarding coordination of benefits with Medicare Part D | ||||||
7 | Prescription Drug Plans. A pharmacy may not charge a | ||||||
8 | Medicare-enrolled beneficiary of the program established under | ||||||
9 | this subsection more for a covered prescription drug than the | ||||||
10 | appropriate Medicare cost-sharing less any payment from or on | ||||||
11 | behalf of the Department of Healthcare and Family Services. | ||||||
12 | The Department of Healthcare and Family Services or the | ||||||
13 | Department on Aging, as appropriate, may adopt rules regarding | ||||||
14 | applications, counting of income, proof of Medicare status, | ||||||
15 | mandatory generic policies, and pharmacy reimbursement rates | ||||||
16 | and any other rules necessary for the cost-efficient operation | ||||||
17 | of the program established under this subsection. | ||||||
18 | (h) A qualified individual is not entitled to duplicate
| ||||||
19 | benefits in a coverage period as a result of the changes made
| ||||||
20 | by this amendatory Act of the 96th General Assembly.
| ||||||
21 | (Source: P.A. 95-208, eff. 8-16-07; 95-644, eff. 10-12-07; | ||||||
22 | 95-876, eff. 8-21-08; 96-804, eff. 1-1-10; revised 9-16-10.)
| ||||||
23 | Section 99. Effective date. This Act takes effect upon | ||||||
24 | becoming law.
|