Rep. Sara Feigenholtz
Filed: 5/27/2011
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1 | AMENDMENT TO SENATE BILL 1802
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2 | AMENDMENT NO. ______. Amend Senate Bill 1802 by replacing | ||||||
3 | everything after the enacting clause with the following:
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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. For State fiscal year 2012, | ||||||
8 | rates for medical services purchased by the Divisions of | ||||||
9 | Alcohol and Substance Abuse, Community Health and Prevention, | ||||||
10 | Developmentally Disabilities, Mental Health, or Rehabilitation | ||||||
11 | Services within the Department of Human Services shall not be | ||||||
12 | reduced below the rates calculated on April 1, 2011 unless the | ||||||
13 | Department of Human Services promulgates rules and rules are | ||||||
14 | implemented authorizing rate reductions. | ||||||
15 | Section 3. The Disabled Persons Rehabilitation Act is |
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1 | amended by adding Section 10a as follows: | ||||||
2 | (20 ILCS 2405/10a new) | ||||||
3 | Sec. 10a. Financial Participation of Students Attending | ||||||
4 | the Illinois School for the Deaf and the Illinois School for | ||||||
5 | the Visually Impaired. | ||||||
6 | (a) General. The Illinois School for the Deaf and the | ||||||
7 | Illinois School for the Visually Impaired are required to | ||||||
8 | provide eligible students with disabilities with a free and | ||||||
9 | appropriate education. As part of the admission process to | ||||||
10 | either school, the Department shall complete a financial | ||||||
11 | analysis on each student attending the Illinois School for the | ||||||
12 | Deaf or the Illinois School for the Visually Impaired and shall | ||||||
13 | ask parents or guardians to participate, if applicable, in the | ||||||
14 | cost of identified services or activities that are not | ||||||
15 | education related. | ||||||
16 | (b) Completion of financial analysis.
Prior to admission, | ||||||
17 | and annually thereafter, a financial analysis shall be | ||||||
18 | completed on each student attending the Illinois School for the | ||||||
19 | Deaf or the Illinois School for the Visually Impaired. If at | ||||||
20 | any time there is reason to believe there is a change in the | ||||||
21 | student's financial situation that will affect their financial | ||||||
22 | participation, a new financial analysis shall be completed. | ||||||
23 | (1) In completing the student's financial analysis, | ||||||
24 | the income of the student's family shall be used. Proof of | ||||||
25 | income must be provided and retained for each parent or |
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1 | guardian. | ||||||
2 | (2) Any funds that have been established on behalf of | ||||||
3 | the student for completion of their primary or secondary | ||||||
4 | education shall be considered when completing the | ||||||
5 | financial analysis. | ||||||
6 | (3) Falsification of information used to complete the | ||||||
7 | financial analysis may result in the Department taking | ||||||
8 | action to recoup monies previously expended by the | ||||||
9 | Department in providing services to the student. | ||||||
10 | (c) Financial Participation. Utilizing a sliding scale | ||||||
11 | based on income standards developed by the Department, parents | ||||||
12 | or guardians of students attending the Illinois School for the | ||||||
13 | Deaf or the Illinois School for the Visually Impaired shall be | ||||||
14 | asked to financially participate in the following fees for | ||||||
15 | services or activities provided at the schools: | ||||||
16 | (1) Registration. | ||||||
17 | (2) Books, labs, and supplies (fees may vary depending | ||||||
18 | on the classes in which a student participates). | ||||||
19 | (3) Room and board for residential students. | ||||||
20 | (4) Meals for day students. | ||||||
21 | (5) Athletic or extracurricular activities (students | ||||||
22 | participating in multiple activities will not be required | ||||||
23 | to pay for more than 2 activities). | ||||||
24 | (6) Driver's education (if applicable). | ||||||
25 | (7) Graduation. | ||||||
26 | (8) Yearbook (optional). |
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1 | (9) Activities (field trips or other leisure | ||||||
2 | activities). | ||||||
3 | (10) Other activities or services identified by the | ||||||
4 | Department. | ||||||
5 | Students, parents, or guardians who are receiving Medicaid | ||||||
6 | or Temporary Assistance for Needy Families (TANF) shall not be | ||||||
7 | required to financially participate in the fees established in | ||||||
8 | this subsection (c). | ||||||
9 | Exceptions may be granted to parents or guardians who are | ||||||
10 | unable to meet the financial participation obligations due to | ||||||
11 | extenuating circumstances. Requests for exceptions must be | ||||||
12 | made in writing and must be submitted to the Director of the | ||||||
13 | Division of Rehabilitation Services for review. | ||||||
14 | Section 5. The State Prompt Payment Act is amended by | ||||||
15 | changing Section 3-2 as follows:
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16 | (30 ILCS 540/3-2)
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17 | Sec. 3-2. Beginning July 1, 1993, in any instance where a | ||||||
18 | State official or
agency is late in payment of a vendor's bill | ||||||
19 | or invoice for goods or services
furnished to the State, as | ||||||
20 | defined in Section 1, properly approved in
accordance with | ||||||
21 | rules promulgated under Section 3-3, the State official or
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22 | agency shall pay interest to the vendor in accordance with the | ||||||
23 | following:
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24 | (1) Any bill , except a bill submitted under Article V |
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1 | of the Illinois Public Aid Code, approved for payment under | ||||||
2 | this Section must be paid
or the payment issued to the | ||||||
3 | payee within 90 60 days of receipt
of a proper bill or | ||||||
4 | invoice.
If payment is not issued to the payee within this | ||||||
5 | 90-day 60 day
period, an
interest penalty of 1.0% of any | ||||||
6 | amount approved and unpaid shall be added
for each month or | ||||||
7 | fraction thereof after the end of this 90-day 60 day | ||||||
8 | period,
until final payment is made. Any bill, except a | ||||||
9 | bill for pharmacy
or nursing facility services or goods, | ||||||
10 | submitted under Article V of the Illinois Public Aid Code | ||||||
11 | approved for payment under this Section must be paid
or the | ||||||
12 | payment issued to the payee within 60 days after receipt
of | ||||||
13 | a proper bill or invoice, and,
if payment is not issued to | ||||||
14 | the payee within this 60-day
period, an
interest penalty of | ||||||
15 | 2.0% of any amount approved and unpaid shall be added
for | ||||||
16 | each month or fraction thereof after the end of this 60-day | ||||||
17 | period,
until final payment is made. Any bill for pharmacy | ||||||
18 | or nursing facility services or
goods submitted under | ||||||
19 | Article V of the Illinois Public Aid
Code, approved for | ||||||
20 | payment under this Section must be paid
or the payment | ||||||
21 | issued to the payee within 60 days of
receipt of a proper | ||||||
22 | bill or invoice. If payment is not
issued to the payee | ||||||
23 | within this 60-day 60 day period, an interest
penalty of | ||||||
24 | 1.0% of any amount approved and unpaid shall be
added for | ||||||
25 | each month or fraction thereof after the end of this 60-day | ||||||
26 | 60 day period, until final payment is made.
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1 | (1.1) A State agency shall review in a timely manner | ||||||
2 | each bill or
invoice after its receipt. If the
State agency | ||||||
3 | determines that the bill or invoice contains a defect | ||||||
4 | making it
unable to process the payment request, the agency
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5 | shall notify the vendor requesting payment as soon as | ||||||
6 | possible after
discovering the
defect pursuant to rules | ||||||
7 | promulgated under Section 3-3; provided, however, that the | ||||||
8 | notice for construction related bills or invoices must be | ||||||
9 | given not later than 30 days after the bill or invoice was | ||||||
10 | first submitted. The notice shall
identify the defect and | ||||||
11 | any additional information
necessary to correct the | ||||||
12 | defect. If one or more items on a construction related bill | ||||||
13 | or invoice are disapproved, but not the entire bill or | ||||||
14 | invoice, then the portion that is not disapproved shall be | ||||||
15 | paid.
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16 | (2) Where a State official or agency is late in payment | ||||||
17 | of a
vendor's bill or invoice properly approved in | ||||||
18 | accordance with this Act, and
different late payment terms | ||||||
19 | are not reduced to writing as a contractual
agreement, the | ||||||
20 | State official or agency shall automatically pay interest
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21 | penalties required by this Section amounting to $50 or more | ||||||
22 | to the appropriate
vendor. Each agency shall be responsible | ||||||
23 | for determining whether an interest
penalty
is
owed and
for | ||||||
24 | paying the interest to the vendor.
Interest due to a vendor | ||||||
25 | that amounts to less than $50 shall not be paid but shall | ||||||
26 | be accrued until all interest due the vendor for all |
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1 | similar warrants exceeds $50, at which time the accrued | ||||||
2 | interest shall be payable and interest will begin accruing | ||||||
3 | again, except that interest accrued as of the end of the | ||||||
4 | fiscal year that does not exceed $50 shall be payable at | ||||||
5 | that time. In the event an
individual has paid a vendor for | ||||||
6 | services in advance, the provisions of this
Section shall | ||||||
7 | apply until payment is made to that individual.
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8 | (3) The provisions of Public Act 96-1501 this | ||||||
9 | amendatory Act of the 96th General Assembly reducing the | ||||||
10 | interest rate on pharmacy claims under Article V of the | ||||||
11 | Illinois Public Aid Code to 1.0% per month shall apply to | ||||||
12 | any pharmacy bills for services and goods under Article V | ||||||
13 | of the Illinois Public Aid Code received on or after the | ||||||
14 | date 60 days before January 25, 2011 ( the effective date of | ||||||
15 | Public Act 96-1501) until the effective date of this | ||||||
16 | amendatory Act of the 97th General Assembly this amendatory | ||||||
17 | Act of the 96th General Assembly . | ||||||
18 | (Source: P.A. 96-555, eff. 8-18-09; 96-802, eff. 1-1-10; | ||||||
19 | 96-959, eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1501, eff. | ||||||
20 | 1-25-11; 96-1530, eff. 2-16-11; revised 2-22-11.)
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21 | Section 10. The Children's Health Insurance Program Act is | ||||||
22 | amended by changing Section 30 as follows:
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23 | (215 ILCS 106/30)
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24 | Sec. 30. Cost sharing.
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1 | (a) Children enrolled in a health benefits program pursuant | ||||||
2 | to subdivision
(a)(2) of Section 25 and persons enrolled in a | ||||||
3 | health benefits waiver program pursuant to Section 40 shall be | ||||||
4 | subject to the following cost sharing
requirements:
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5 | (1) There shall be no co-payment required for well-baby | ||||||
6 | or well-child
care, including age-appropriate | ||||||
7 | immunizations as required under
federal law.
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8 | (2) Health insurance premiums for family members, | ||||||
9 | either children or adults, in families whose household
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10 | income is above 150% of the federal poverty level shall be | ||||||
11 | payable
monthly, subject to rules promulgated by the | ||||||
12 | Department for grace periods and
advance payments, and | ||||||
13 | shall be as follows:
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14 | (A) $15 per month for one family member.
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15 | (B) $25 per month for 2 family members.
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16 | (C) $30 per month for 3 family members. | ||||||
17 | (D) $35 per month for 4 family members. | ||||||
18 | (E) $40 per month for 5 or more family members.
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19 | (3) Co-payments for children or adults in families | ||||||
20 | whose income is at or below
150% of the federal poverty | ||||||
21 | level, at a minimum and to the extent permitted
under | ||||||
22 | federal law, shall be $2 for all medical visits and | ||||||
23 | prescriptions
provided under this Act and up to $10 for | ||||||
24 | emergency room use for a non-emergency situation as defined | ||||||
25 | by the Department by rule and subject to federal approval .
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26 | (4) Co-payments for children or adults in families |
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1 | whose income is above 150%
of the federal poverty level, at | ||||||
2 | a minimum and to the extent permitted under
federal law | ||||||
3 | shall be as follows:
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4 | (A) $5 for medical visits.
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5 | (B) $3 for generic prescriptions and $5 for brand | ||||||
6 | name
prescriptions.
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7 | (C) $25 for emergency room use for a non-emergency
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8 | situation as defined by the Department by rule.
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9 | (5) (Blank) The maximum amount of out-of-pocket | ||||||
10 | expenses for co-payments shall be
$100 per family per year .
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11 | (6) Co-payments shall be maximized to the extent | ||||||
12 | permitted by federal law and are subject to federal | ||||||
13 | approval. | ||||||
14 | (b) Individuals enrolled in a privately sponsored health | ||||||
15 | insurance plan
pursuant to subdivision (a)(1) of Section 25 | ||||||
16 | shall be subject to the cost
sharing provisions as stated in | ||||||
17 | the privately sponsored health insurance plan.
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18 | (Source: P.A. 94-48, eff. 7-1-05.)
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19 | Section 15. The Illinois Public Aid Code is amended by | ||||||
20 | changing Sections 5-2, 5-4.1, 5-5.12, 5A-10, 14-8, as follows:
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21 | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
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22 | Sec. 5-2. Classes of Persons Eligible. Medical assistance | ||||||
23 | under this
Article shall be available to any of the following | ||||||
24 | classes of persons in
respect to whom a plan for coverage has |
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1 | been submitted to the Governor
by the Illinois Department and | ||||||
2 | approved by him:
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3 | 1. Recipients of basic maintenance grants under | ||||||
4 | Articles III and IV.
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5 | 2. Persons otherwise eligible for basic maintenance | ||||||
6 | under Articles
III and IV, excluding any eligibility | ||||||
7 | requirements that are inconsistent with any federal law or | ||||||
8 | federal regulation, as interpreted by the U.S. Department | ||||||
9 | of Health and Human Services, but who fail to qualify | ||||||
10 | thereunder on the basis of need or who qualify but are not | ||||||
11 | receiving basic maintenance under Article IV, and
who have | ||||||
12 | insufficient income and resources to meet the costs of
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13 | necessary medical care, including but not limited to the | ||||||
14 | following:
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15 | (a) All persons otherwise eligible for basic | ||||||
16 | maintenance under Article
III but who fail to qualify | ||||||
17 | under that Article on the basis of need and who
meet | ||||||
18 | either of the following requirements:
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19 | (i) their income, as determined by the | ||||||
20 | Illinois Department in
accordance with any federal | ||||||
21 | requirements, is equal to or less than 70% in
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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
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25 | than 100% beginning on the date determined by the | ||||||
26 | Department by rule, of the nonfarm income official |
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1 | poverty
line, as defined by the federal Office of | ||||||
2 | Management and Budget and revised
annually in | ||||||
3 | accordance with Section 673(2) of the Omnibus | ||||||
4 | Budget Reconciliation
Act of 1981, applicable to | ||||||
5 | families of the same size; or
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6 | (ii) their income, after the deduction of | ||||||
7 | costs incurred for medical
care and for other types | ||||||
8 | of remedial care, is equal to or less than 70% in
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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
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12 | than 100% beginning on the date determined by the | ||||||
13 | Department by rule, of the nonfarm income official | ||||||
14 | poverty
line, as defined in item (i) of this | ||||||
15 | subparagraph (a).
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16 | (b) All persons who, excluding any eligibility | ||||||
17 | requirements that are inconsistent with any federal | ||||||
18 | law or federal regulation, as interpreted by the U.S. | ||||||
19 | Department of Health and Human Services, would be | ||||||
20 | determined eligible for such basic
maintenance under | ||||||
21 | Article IV by disregarding the maximum earned income
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22 | permitted by federal law.
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23 | 3. Persons who would otherwise qualify for Aid to the | ||||||
24 | Medically
Indigent under Article VII.
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25 | 4. Persons not eligible under any of the preceding | ||||||
26 | paragraphs who fall
sick, are injured, or die, not having |
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1 | sufficient money, property or other
resources to meet the | ||||||
2 | costs of necessary medical care or funeral and burial
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3 | expenses.
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4 | 5.(a) Women during pregnancy, after the fact
of | ||||||
5 | pregnancy has been determined by medical diagnosis, and | ||||||
6 | during the
60-day period beginning on the last day of the | ||||||
7 | pregnancy, together with
their infants and children born | ||||||
8 | after September 30, 1983,
whose income and
resources are | ||||||
9 | insufficient to meet the costs of necessary medical care to
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10 | the maximum extent possible under Title XIX of the
Federal | ||||||
11 | Social Security Act.
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12 | (b) The Illinois Department and the Governor shall | ||||||
13 | provide a plan for
coverage of the persons eligible under | ||||||
14 | paragraph 5(a) by April 1, 1990. Such
plan shall provide | ||||||
15 | ambulatory prenatal care to pregnant women during a
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16 | presumptive eligibility period and establish an income | ||||||
17 | eligibility standard
that is equal to 133%
of the nonfarm | ||||||
18 | income official poverty line, as defined by
the federal | ||||||
19 | Office of Management and Budget and revised annually in
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20 | accordance with Section 673(2) of the Omnibus Budget | ||||||
21 | Reconciliation Act of
1981, applicable to families of the | ||||||
22 | same size, provided that costs incurred
for medical care | ||||||
23 | are not taken into account in determining such income
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24 | eligibility.
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25 | (c) The Illinois Department may conduct a | ||||||
26 | demonstration in at least one
county that will provide |
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1 | medical assistance to pregnant women, together
with their | ||||||
2 | infants and children up to one year of age,
where the | ||||||
3 | income
eligibility standard is set up to 185% of the | ||||||
4 | nonfarm income official
poverty line, as defined by the | ||||||
5 | federal Office of Management and Budget.
The Illinois | ||||||
6 | Department shall seek and obtain necessary authorization
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7 | provided under federal law to implement such a | ||||||
8 | demonstration. Such
demonstration may establish resource | ||||||
9 | standards that are not more
restrictive than those | ||||||
10 | established under Article IV of this Code.
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11 | 6. Persons under the age of 18 who fail to qualify as | ||||||
12 | dependent under
Article IV and who have insufficient income | ||||||
13 | and resources to meet the costs
of necessary medical care | ||||||
14 | to the maximum extent permitted under Title XIX
of the | ||||||
15 | Federal Social Security Act.
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16 | 7. Persons who are under 21 years of age and would
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17 | qualify as
disabled as defined under the Federal | ||||||
18 | Supplemental Security Income Program,
provided medical | ||||||
19 | service for such persons would be eligible for Federal
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20 | Financial Participation, and provided the Illinois | ||||||
21 | Department determines that:
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22 | (a) the person requires a level of care provided by | ||||||
23 | a hospital, skilled
nursing facility, or intermediate | ||||||
24 | care facility, as determined by a physician
licensed to | ||||||
25 | practice medicine in all its branches;
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26 | (b) it is appropriate to provide such care outside |
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1 | of an institution, as
determined by a physician | ||||||
2 | licensed to practice medicine in all its branches;
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3 | (c) the estimated amount which would be expended | ||||||
4 | for care outside the
institution is not greater than | ||||||
5 | the estimated amount which would be
expended in an | ||||||
6 | institution.
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7 | 8. Persons who become ineligible for basic maintenance | ||||||
8 | assistance
under Article IV of this Code in programs | ||||||
9 | administered by the Illinois
Department due to employment | ||||||
10 | earnings and persons in
assistance units comprised of | ||||||
11 | adults and children who become ineligible for
basic | ||||||
12 | maintenance assistance under Article VI of this Code due to
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13 | employment earnings. The plan for coverage for this class | ||||||
14 | of persons shall:
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15 | (a) extend the medical assistance coverage for up | ||||||
16 | to 12 months following
termination of basic | ||||||
17 | maintenance assistance; and
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18 | (b) offer persons who have initially received 6 | ||||||
19 | months of the
coverage provided in paragraph (a) above, | ||||||
20 | the option of receiving an
additional 6 months of | ||||||
21 | coverage, subject to the following:
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22 | (i) such coverage shall be pursuant to | ||||||
23 | provisions of the federal
Social Security Act;
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24 | (ii) such coverage shall include all services | ||||||
25 | covered while the person
was eligible for basic | ||||||
26 | maintenance assistance;
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1 | (iii) no premium shall be charged for such | ||||||
2 | coverage; and
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3 | (iv) such coverage shall be suspended in the | ||||||
4 | event of a person's
failure without good cause to | ||||||
5 | file in a timely fashion reports required for
this | ||||||
6 | coverage under the Social Security Act and | ||||||
7 | coverage shall be reinstated
upon the filing of | ||||||
8 | such reports if the person remains otherwise | ||||||
9 | eligible.
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10 | 9. Persons with acquired immunodeficiency syndrome | ||||||
11 | (AIDS) or with
AIDS-related conditions with respect to whom | ||||||
12 | there has been a determination
that but for home or | ||||||
13 | community-based services such individuals would
require | ||||||
14 | the level of care provided in an inpatient hospital, | ||||||
15 | skilled
nursing facility or intermediate care facility the | ||||||
16 | cost of which is
reimbursed under this Article. Assistance | ||||||
17 | shall be provided to such
persons to the maximum extent | ||||||
18 | permitted under Title
XIX of the Federal Social Security | ||||||
19 | Act.
| ||||||
20 | 10. Participants in the long-term care insurance | ||||||
21 | partnership program
established under the Illinois | ||||||
22 | Long-Term Care Partnership Program Act who meet the
| ||||||
23 | qualifications for protection of resources described in | ||||||
24 | Section 15 of that
Act.
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25 | 11. Persons with disabilities who are employed and | ||||||
26 | eligible for Medicaid,
pursuant to Section |
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1 | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, | ||||||
2 | subject to federal approval, persons with a medically | ||||||
3 | improved disability who are employed and eligible for | ||||||
4 | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | ||||||
5 | the Social Security Act, as
provided by the Illinois | ||||||
6 | Department by rule. In establishing eligibility standards | ||||||
7 | under this paragraph 11, the Department shall, subject to | ||||||
8 | federal approval: | ||||||
9 | (a) set the income eligibility standard at not | ||||||
10 | lower than 350% of the federal poverty level; | ||||||
11 | (b) exempt retirement accounts that the person | ||||||
12 | cannot access without penalty before the age
of 59 1/2, | ||||||
13 | and medical savings accounts established pursuant to | ||||||
14 | 26 U.S.C. 220; | ||||||
15 | (c) allow non-exempt assets up to $25,000 as to | ||||||
16 | those assets accumulated during periods of eligibility | ||||||
17 | under this paragraph 11; and
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18 | (d) continue to apply subparagraphs (b) and (c) in | ||||||
19 | determining the eligibility of the person under this | ||||||
20 | Article even if the person loses eligibility under this | ||||||
21 | paragraph 11.
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22 | 12. Subject to federal approval, persons who are | ||||||
23 | eligible for medical
assistance coverage under applicable | ||||||
24 | provisions of the federal Social Security
Act and the | ||||||
25 | federal Breast and Cervical Cancer Prevention and | ||||||
26 | Treatment Act of
2000. Those eligible persons are defined |
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1 | to include, but not be limited to,
the following persons:
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2 | (1) persons who have been screened for breast or | ||||||
3 | cervical cancer under
the U.S. Centers for Disease | ||||||
4 | Control and Prevention Breast and Cervical Cancer
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5 | Program established under Title XV of the federal | ||||||
6 | Public Health Services Act in
accordance with the | ||||||
7 | requirements of Section 1504 of that Act as | ||||||
8 | administered by
the Illinois Department of Public | ||||||
9 | Health; and
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10 | (2) persons whose screenings under the above | ||||||
11 | program were funded in whole
or in part by funds | ||||||
12 | appropriated to the Illinois Department of Public | ||||||
13 | Health
for breast or cervical cancer screening.
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14 | "Medical assistance" under this paragraph 12 shall be | ||||||
15 | identical to the benefits
provided under the State's | ||||||
16 | approved plan under Title XIX of the Social Security
Act. | ||||||
17 | The Department must request federal approval of the | ||||||
18 | coverage under this
paragraph 12 within 30 days after the | ||||||
19 | effective date of this amendatory Act of
the 92nd General | ||||||
20 | Assembly.
| ||||||
21 | In addition to the persons who are eligible for medical | ||||||
22 | assistance pursuant to subparagraphs (1) and (2) of this | ||||||
23 | paragraph 12, and to be paid from funds appropriated to the | ||||||
24 | Department for its medical programs, any uninsured person | ||||||
25 | as defined by the Department in rules residing in Illinois | ||||||
26 | who is younger than 65 years of age, who has been screened |
| |||||||
| |||||||
1 | for breast and cervical cancer in accordance with standards | ||||||
2 | and procedures adopted by the Department of Public Health | ||||||
3 | for screening, and who is referred to the Department by the | ||||||
4 | Department of Public Health as being in need of treatment | ||||||
5 | for breast or cervical cancer is eligible for medical | ||||||
6 | assistance benefits that are consistent with the benefits | ||||||
7 | provided to those persons described in subparagraphs (1) | ||||||
8 | and (2). Medical assistance coverage for the persons who | ||||||
9 | are eligible under the preceding sentence is not dependent | ||||||
10 | on federal approval, but federal moneys may be used to pay | ||||||
11 | for services provided under that coverage upon federal | ||||||
12 | approval. | ||||||
13 | 13. Subject to appropriation and to federal approval, | ||||||
14 | persons living with HIV/AIDS who are not otherwise eligible | ||||||
15 | under this Article and who qualify for services covered | ||||||
16 | under Section 5-5.04 as provided by the Illinois Department | ||||||
17 | by rule.
| ||||||
18 | 14. Subject to the availability of funds for this | ||||||
19 | purpose, the Department may provide coverage under this | ||||||
20 | Article to persons who reside in Illinois who are not | ||||||
21 | eligible under any of the preceding paragraphs and who meet | ||||||
22 | the income guidelines of paragraph 2(a) of this Section and | ||||||
23 | (i) have an application for asylum pending before the | ||||||
24 | federal Department of Homeland Security or on appeal before | ||||||
25 | a court of competent jurisdiction and are represented | ||||||
26 | either by counsel or by an advocate accredited by the |
| |||||||
| |||||||
1 | federal Department of Homeland Security and employed by a | ||||||
2 | not-for-profit organization in regard to that application | ||||||
3 | or appeal, or (ii) are receiving services through a | ||||||
4 | federally funded torture treatment center. Medical | ||||||
5 | coverage under this paragraph 14 may be provided for up to | ||||||
6 | 24 continuous months from the initial eligibility date so | ||||||
7 | long as an individual continues to satisfy the criteria of | ||||||
8 | this paragraph 14. If an individual has an appeal pending | ||||||
9 | regarding an application for asylum before the Department | ||||||
10 | of Homeland Security, eligibility under this paragraph 14 | ||||||
11 | may be extended until a final decision is rendered on the | ||||||
12 | appeal. The Department may adopt rules governing the | ||||||
13 | implementation of this paragraph 14.
| ||||||
14 | 15. Family Care Eligibility. | ||||||
15 | (a) Through December 31, 2013, a A caretaker | ||||||
16 | relative who is 19 years of age or older when countable | ||||||
17 | income is at or below 185% of the Federal Poverty Level | ||||||
18 | Guidelines, as published annually in the Federal | ||||||
19 | Register, for the appropriate family size. Beginning | ||||||
20 | January 1, 2014, a caretaker relative who is 19 years | ||||||
21 | of age or older when countable income is at or below | ||||||
22 | 133% of the Federal Poverty Level Guidelines, as | ||||||
23 | published annually in the Federal Register, for the | ||||||
24 | appropriate family size. A person may not spend down to | ||||||
25 | become eligible under this paragraph 15. | ||||||
26 | (b) Eligibility shall be reviewed annually. |
| |||||||
| |||||||
1 | (c) Caretaker relatives enrolled under this | ||||||
2 | paragraph 15 in families with countable income above | ||||||
3 | 150% and at or below 185% of the Federal Poverty Level | ||||||
4 | Guidelines shall be counted as family members and pay | ||||||
5 | premiums as established under the Children's Health | ||||||
6 | Insurance Program Act. | ||||||
7 | (d) Premiums shall be billed by and payable to the | ||||||
8 | Department or its authorized agent, on a monthly basis. | ||||||
9 | (e) The premium due date is the last day of the | ||||||
10 | month preceding the month of coverage. | ||||||
11 | (f) Individuals shall have a grace period through | ||||||
12 | 30 days of coverage to pay the premium. | ||||||
13 | (g) Failure to pay the full monthly premium by the | ||||||
14 | last day of the grace period shall result in | ||||||
15 | termination of coverage. | ||||||
16 | (h) Partial premium payments shall not be | ||||||
17 | refunded. | ||||||
18 | (i) Following termination of an individual's | ||||||
19 | coverage under this paragraph 15, the following action | ||||||
20 | is required before the individual can be re-enrolled: | ||||||
21 | (1) A new application must be completed and the | ||||||
22 | individual must be determined otherwise eligible. | ||||||
23 | (2) There must be full payment of premiums due | ||||||
24 | under this Code, the Children's Health Insurance | ||||||
25 | Program Act, the Covering ALL KIDS Health | ||||||
26 | Insurance Act, or any other healthcare program |
| |||||||
| |||||||
1 | administered by the Department for periods in | ||||||
2 | which a premium was owed and not paid for the | ||||||
3 | individual. | ||||||
4 | (3) The first month's premium must be paid if | ||||||
5 | there was an unpaid premium on the date the | ||||||
6 | individual's previous coverage was canceled. | ||||||
7 | The Department is authorized to implement the | ||||||
8 | provisions of this amendatory Act of the 95th General | ||||||
9 | Assembly by adopting the medical assistance rules in effect | ||||||
10 | as of October 1, 2007, at 89 Ill. Admin. Code 125, and at | ||||||
11 | 89 Ill. Admin. Code 120.32 along with only those changes | ||||||
12 | necessary to conform to federal Medicaid requirements, | ||||||
13 | federal laws, and federal regulations, including but not | ||||||
14 | limited to Section 1931 of the Social Security Act (42 | ||||||
15 | U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department | ||||||
16 | of Health and Human Services, and the countable income | ||||||
17 | eligibility standard authorized by this paragraph 15. The | ||||||
18 | Department may not otherwise adopt any rule to implement | ||||||
19 | this increase except as authorized by law, to meet the | ||||||
20 | eligibility standards authorized by the federal government | ||||||
21 | in the Medicaid State Plan or the Title XXI Plan, or to | ||||||
22 | meet an order from the federal government or any court. | ||||||
23 | 16. Subject to appropriation, uninsured persons who | ||||||
24 | are not otherwise eligible under this Section who have been | ||||||
25 | certified and referred by the Department of Public Health | ||||||
26 | as having been screened and found to need diagnostic |
| |||||||
| |||||||
1 | evaluation or treatment, or both diagnostic evaluation and | ||||||
2 | treatment, for prostate or testicular cancer. For the | ||||||
3 | purposes of this paragraph 16, uninsured persons are those | ||||||
4 | who do not have creditable coverage, as defined under the | ||||||
5 | Health Insurance Portability and Accountability Act, or | ||||||
6 | have otherwise exhausted any insurance benefits they may | ||||||
7 | have had, for prostate or testicular cancer diagnostic | ||||||
8 | evaluation or treatment, or both diagnostic evaluation and | ||||||
9 | treatment.
To be eligible, a person must furnish a Social | ||||||
10 | Security number.
A person's assets are exempt from | ||||||
11 | consideration in determining eligibility under this | ||||||
12 | paragraph 16.
Such persons shall be eligible for medical | ||||||
13 | assistance under this paragraph 16 for so long as they need | ||||||
14 | treatment for the cancer. A person shall be considered to | ||||||
15 | need treatment if, in the opinion of the person's treating | ||||||
16 | physician, the person requires therapy directed toward | ||||||
17 | cure or palliation of prostate or testicular cancer, | ||||||
18 | including recurrent metastatic cancer that is a known or | ||||||
19 | presumed complication of prostate or testicular cancer and | ||||||
20 | complications resulting from the treatment modalities | ||||||
21 | themselves. Persons who require only routine monitoring | ||||||
22 | services are not considered to need treatment.
"Medical | ||||||
23 | assistance" under this paragraph 16 shall be identical to | ||||||
24 | the benefits provided under the State's approved plan under | ||||||
25 | Title XIX of the Social Security Act.
Notwithstanding any | ||||||
26 | other provision of law, the Department (i) does not have a |
| |||||||
| |||||||
1 | claim against the estate of a deceased recipient of | ||||||
2 | services under this paragraph 16 and (ii) does not have a | ||||||
3 | lien against any homestead property or other legal or | ||||||
4 | equitable real property interest owned by a recipient of | ||||||
5 | services under this paragraph 16. | ||||||
6 | In implementing the provisions of Public Act 96-20, the | ||||||
7 | Department is authorized to adopt only those rules necessary, | ||||||
8 | including emergency rules. Nothing in Public Act 96-20 permits | ||||||
9 | the Department to adopt rules or issue a decision that expands | ||||||
10 | eligibility for the FamilyCare Program to a person whose income | ||||||
11 | exceeds 185% of the Federal Poverty Level as determined from | ||||||
12 | time to time by the U.S. Department of Health and Human | ||||||
13 | Services, unless the Department is provided with express | ||||||
14 | statutory authority. | ||||||
15 | The Illinois Department and the Governor shall provide a | ||||||
16 | plan for
coverage of the persons eligible under paragraph 7 as | ||||||
17 | soon as possible after
July 1, 1984.
| ||||||
18 | The eligibility of any such person for medical assistance | ||||||
19 | under this
Article is not affected by the payment of any grant | ||||||
20 | under the Senior
Citizens and Disabled Persons Property Tax | ||||||
21 | Relief and Pharmaceutical
Assistance Act or any distributions | ||||||
22 | or items of income described under
subparagraph (X) of
| ||||||
23 | paragraph (2) of subsection (a) of Section 203 of the Illinois | ||||||
24 | Income Tax
Act. The Department shall by rule establish the | ||||||
25 | amounts of
assets to be disregarded in determining eligibility | ||||||
26 | for medical assistance,
which shall at a minimum equal the |
| |||||||
| |||||||
1 | amounts to be disregarded under the
Federal Supplemental | ||||||
2 | Security Income Program. The amount of assets of a
single | ||||||
3 | person to be disregarded
shall not be less than $2,000, and the | ||||||
4 | amount of assets of a married couple
to be disregarded shall | ||||||
5 | not be less than $3,000.
| ||||||
6 | To the extent permitted under federal law, any person found | ||||||
7 | guilty of a
second violation of Article VIIIA
shall be | ||||||
8 | ineligible for medical assistance under this Article, as | ||||||
9 | provided
in Section 8A-8.
| ||||||
10 | The eligibility of any person for medical assistance under | ||||||
11 | this Article
shall not be affected by the receipt by the person | ||||||
12 | of donations or benefits
from fundraisers held for the person | ||||||
13 | in cases of serious illness,
as long as neither the person nor | ||||||
14 | members of the person's family
have actual control over the | ||||||
15 | donations or benefits or the disbursement
of the donations or | ||||||
16 | benefits.
| ||||||
17 | (Source: P.A. 95-546, eff. 8-29-07; 95-1055, eff. 4-10-09; | ||||||
18 | 96-20, eff. 6-30-09; 96-181, eff. 8-10-09; 96-328, eff. | ||||||
19 | 8-11-09; 96-567, eff. 1-1-10; 96-1000, eff. 7-2-10; 96-1123, | ||||||
20 | eff. 1-1-11; 96-1270, eff. 7-26-10; revised 9-16-10.)
| ||||||
21 | (305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
| ||||||
22 | Sec. 5-4.1. Co-payments. The Department may by rule provide | ||||||
23 | that recipients
under any Article of this Code shall pay a fee | ||||||
24 | as a co-payment for services.
Co-payments shall be maximized to | ||||||
25 | the extent permitted by federal law. Provided, however, that |
| |||||||
| |||||||
1 | any such rule must provide that no
co-payment requirement can | ||||||
2 | exist
for renal dialysis, radiation therapy, cancer | ||||||
3 | chemotherapy, or insulin, and
other products necessary on a | ||||||
4 | recurring basis, the absence of which would
be life | ||||||
5 | threatening, or where co-payment expenditures for required | ||||||
6 | services
and/or medications for chronic diseases that the | ||||||
7 | Illinois Department shall
by rule designate shall cause an | ||||||
8 | extensive financial burden on the
recipient, and provided no | ||||||
9 | co-payment shall exist for emergency room
encounters which are | ||||||
10 | for medical emergencies. The Department shall seek approval of | ||||||
11 | a State plan amendment that allows pharmacies to refuse to | ||||||
12 | dispense drugs in circumstances where the recipient does not | ||||||
13 | pay the required co-payment. In the event the State plan | ||||||
14 | amendment is rejected, co-payments may not exceed $3 for brand | ||||||
15 | name drugs, $1 for other pharmacy
services other than for | ||||||
16 | generic drugs, and $2 for physician services, dental
services, | ||||||
17 | optical services and supplies, chiropractic services, podiatry
| ||||||
18 | services, and encounter rate clinic services. There shall be no | ||||||
19 | co-payment for
generic drugs. Co-payments may not exceed $10 | ||||||
20 | for emergency room use for a non-emergency situation as defined | ||||||
21 | by the Department by rule and subject to federal approval. | ||||||
22 | Co-payments may not exceed $3 for hospital outpatient and | ||||||
23 | clinic
services.
| ||||||
24 | (Source: P.A. 96-1501, eff. 1-25-11.)
| ||||||
25 | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
|
| |||||||
| |||||||
1 | Sec. 5-5.12. Pharmacy payments.
| ||||||
2 | (a) Every request submitted by a pharmacy for reimbursement | ||||||
3 | under this
Article for prescription drugs provided to a | ||||||
4 | recipient of aid under this
Article shall include the name of | ||||||
5 | the prescriber or an acceptable
identification number as | ||||||
6 | established by the Department.
| ||||||
7 | (b) Pharmacies providing prescription drugs under
this | ||||||
8 | Article shall be reimbursed at a rate which shall include
a | ||||||
9 | professional dispensing fee as determined by the Illinois
| ||||||
10 | Department, plus the current acquisition cost of the | ||||||
11 | prescription
drug dispensed. The Illinois Department shall | ||||||
12 | update its
information on the acquisition costs of all | ||||||
13 | prescription drugs
no less frequently than every 30 days. | ||||||
14 | However, the Illinois
Department may set the rate of | ||||||
15 | reimbursement for the acquisition
cost, by rule, at a | ||||||
16 | percentage of the current average wholesale
acquisition cost.
| ||||||
17 | (c) (Blank).
| ||||||
18 | (d) The Department shall not impose requirements for prior | ||||||
19 | approval
based on a preferred drug list for anti-retroviral, | ||||||
20 | anti-hemophilic factor
concentrates,
or
any atypical | ||||||
21 | antipsychotics, conventional antipsychotics,
or | ||||||
22 | anticonvulsants used for the treatment of serious mental
| ||||||
23 | illnesses
until 30 days after it has conducted a study of the | ||||||
24 | impact of such
requirements on patient care and submitted a | ||||||
25 | report to the Speaker of the
House of Representatives and the | ||||||
26 | President of the Senate. The Department shall review |
| |||||||
| |||||||
1 | utilization of narcotic medications in the medical assistance | ||||||
2 | program and impose utilization controls that protect against | ||||||
3 | abuse.
| ||||||
4 | (e) When making determinations as to which drugs shall be | ||||||
5 | on a prior approval list, the Department shall include as part | ||||||
6 | of the analysis for this determination, the degree to which a | ||||||
7 | drug may affect individuals in different ways based on factors | ||||||
8 | including the gender of the person taking the medication. | ||||||
9 | (f) The Department shall cooperate with the Department of | ||||||
10 | Public Health and the Department of Human Services Division of | ||||||
11 | Mental Health in identifying psychotropic medications that, | ||||||
12 | when given in a particular form, manner, duration, or frequency | ||||||
13 | (including "as needed") in a dosage, or in conjunction with | ||||||
14 | other psychotropic medications to a nursing home resident, may | ||||||
15 | constitute a chemical restraint or an "unnecessary drug" as | ||||||
16 | defined by the Nursing Home Care Act or Titles XVIII and XIX of | ||||||
17 | the Social Security Act and the implementing rules and | ||||||
18 | regulations. The Department shall require prior approval for | ||||||
19 | any such medication prescribed for a nursing home resident that | ||||||
20 | appears to be a chemical restraint or an unnecessary drug. The | ||||||
21 | Department shall consult with the Department of Human Services | ||||||
22 | Division of Mental Health in developing a protocol and criteria | ||||||
23 | for deciding whether to grant such prior approval. | ||||||
24 | (g) The Department may by rule provide for reimbursement of | ||||||
25 | the dispensing of a 90-day supply of a generic, non-narcotic | ||||||
26 | maintenance medication in circumstances where it is cost |
| |||||||
| |||||||
1 | effective. | ||||||
2 | (h) Effective July 1, 2011, the Department shall | ||||||
3 | discontinue coverage of select over-the-counter drugs, | ||||||
4 | including analgesics and cough and cold and allergy | ||||||
5 | medications. | ||||||
6 | (i) The Department shall seek any necessary waiver from the | ||||||
7 | federal government in order to establish a program limiting the | ||||||
8 | pharmacies eligible to dispense specialty drugs and shall issue | ||||||
9 | a Request for Proposals in order to maximize savings on these | ||||||
10 | drugs. The Department shall by rule establish the drugs | ||||||
11 | required to be dispensed in this program. | ||||||
12 | (Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10; | ||||||
13 | 96-1501, eff. 1-25-11.)
| ||||||
14 | (305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)
| ||||||
15 | Sec. 5A-10. Applicability.
| ||||||
16 | (a) The assessment imposed by Section 5A-2 shall not take | ||||||
17 | effect or shall
cease to be imposed, and
any moneys
remaining | ||||||
18 | in the Fund shall be refunded to hospital providers
in | ||||||
19 | proportion to the amounts paid by them, if:
| ||||||
20 | (1) The sum of the appropriations for State fiscal | ||||||
21 | years 2004 and 2005
from the
General Revenue Fund for | ||||||
22 | hospital payments
under the medical assistance program is | ||||||
23 | less than $4,500,000,000 or the appropriation for each of | ||||||
24 | State fiscal years 2006, 2007 and 2008 from the General | ||||||
25 | Revenue Fund for hospital payments under the medical |
| |||||||
| |||||||
1 | assistance program is less than $2,500,000,000 increased | ||||||
2 | annually to reflect any increase in the number of | ||||||
3 | recipients, or the annual appropriation for State fiscal | ||||||
4 | years 2009 , 2010, 2011, 2013, and 2014 through 2014 , from | ||||||
5 | the General Revenue Fund combined with the Hospital | ||||||
6 | Provider Fund as authorized in Section 5A-8 for hospital | ||||||
7 | payments under the medical assistance program, is less than | ||||||
8 | the amount appropriated for State fiscal year 2009, | ||||||
9 | adjusted annually to reflect any change in the number of | ||||||
10 | recipients, excluding State fiscal year 2009 supplemental | ||||||
11 | appropriations made necessary by the enactment of the | ||||||
12 | American Recovery and Reinvestment Act of 2009; or
| ||||||
13 | (2) For State fiscal years prior to State fiscal year | ||||||
14 | 2009, the Department of Healthcare and Family Services | ||||||
15 | (formerly Department of Public Aid) makes changes in its | ||||||
16 | rules
that
reduce the hospital inpatient or outpatient | ||||||
17 | payment rates, including adjustment
payment rates, in | ||||||
18 | effect on October 1, 2004, except for hospitals described | ||||||
19 | in
subsection (b) of Section 5A-3 and except for changes in | ||||||
20 | the methodology for calculating outlier payments to | ||||||
21 | hospitals for exceptionally costly stays, so long as those | ||||||
22 | changes do not reduce aggregate
expenditures below the | ||||||
23 | amount expended in State fiscal year 2005 for such
| ||||||
24 | services; or
| ||||||
25 | (2.1) For State fiscal years 2009 , 2010, 2011, 2013, | ||||||
26 | and 2014 through 2014 , the
Department of Healthcare and |
| |||||||
| |||||||
1 | Family Services adopts any administrative rule change to | ||||||
2 | reduce payment rates or alters any payment methodology that | ||||||
3 | reduces any payment rates made to operating hospitals under | ||||||
4 | the approved Title XIX or Title XXI State plan in effect | ||||||
5 | January 1, 2008 except for: | ||||||
6 | (A) any changes for hospitals described in | ||||||
7 | subsection (b) of Section 5A-3; or | ||||||
8 | (B) any rates for payments made under this Article | ||||||
9 | V-A; or | ||||||
10 | (C) any changes proposed in State plan amendment | ||||||
11 | transmittal numbers 08-01, 08-02, 08-04, 08-06, and | ||||||
12 | 08-07; or | ||||||
13 | (D) in relation to any admissions on or after | ||||||
14 | January 1, 2011, a modification in the methodology for | ||||||
15 | calculating outlier payments to hospitals for | ||||||
16 | exceptionally costly stays, for hospitals reimbursed | ||||||
17 | under the diagnosis-related grouping methodology; | ||||||
18 | provided that the Department shall be limited to one | ||||||
19 | such modification during the 36-month period after the | ||||||
20 | effective date of this amendatory Act of the 96th | ||||||
21 | General Assembly; or | ||||||
22 | (E) changes in hospital payment rates related to | ||||||
23 | potentially preventable readmissions as described in | ||||||
24 | Section 14-8 of this Code; or | ||||||
25 | (3) The payments to hospitals required under Section | ||||||
26 | 5A-12 or Section 5A-12.2 are changed or
are
not eligible |
| |||||||
| |||||||
1 | for federal matching funds under Title XIX or XXI of the | ||||||
2 | Social
Security Act.
| ||||||
3 | (b) The assessment imposed by Section 5A-2 shall not take | ||||||
4 | effect or
shall
cease to be imposed if the assessment is | ||||||
5 | determined to be an impermissible
tax under Title XIX
of the | ||||||
6 | Social Security Act. Moneys in the Hospital Provider Fund | ||||||
7 | derived
from assessments imposed prior thereto shall be
| ||||||
8 | disbursed in accordance with Section 5A-8 to the extent federal | ||||||
9 | financial participation is
not reduced due to the | ||||||
10 | impermissibility of the assessments, and any
remaining
moneys | ||||||
11 | shall be
refunded to hospital providers in proportion to the | ||||||
12 | amounts paid by them.
| ||||||
13 | (Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08; 96-8, | ||||||
14 | eff. 4-28-09; 96-1530, eff. 2-16-11.)
| ||||||
15 | (305 ILCS 5/14-8) (from Ch. 23, par. 14-8)
| ||||||
16 | Sec. 14-8. Disbursements to Hospitals.
| ||||||
17 | (a) For inpatient hospital services rendered on and after | ||||||
18 | September 1,
1991, the Illinois Department shall reimburse
| ||||||
19 | hospitals for inpatient services at an inpatient payment rate | ||||||
20 | calculated for
each hospital based upon the Medicare | ||||||
21 | Prospective Payment System as set forth
in Sections 1886(b), | ||||||
22 | (d), (g), and (h) of the federal Social Security Act, and
the | ||||||
23 | regulations, policies, and procedures promulgated thereunder, | ||||||
24 | except as
modified by this Section. Payment rates for inpatient | ||||||
25 | hospital services
rendered on or after September 1, 1991 and on |
| |||||||
| |||||||
1 | or before September 30, 1992
shall be calculated using the | ||||||
2 | Medicare Prospective Payment rates in effect on
September 1, | ||||||
3 | 1991. Payment rates for inpatient hospital services rendered on
| ||||||
4 | or after October 1, 1992 and on or before March 31, 1994 shall | ||||||
5 | be calculated
using the Medicare Prospective Payment rates in | ||||||
6 | effect on September 1, 1992.
Payment rates for inpatient | ||||||
7 | hospital services rendered on or after April 1,
1994 shall be | ||||||
8 | calculated using the Medicare Prospective Payment rates
| ||||||
9 | (including the Medicare grouping methodology and weighting | ||||||
10 | factors as adjusted
pursuant to paragraph (1) of this | ||||||
11 | subsection) in effect 90 days prior to the
date of admission. | ||||||
12 | For services rendered on or after July 1, 1995, the
| ||||||
13 | reimbursement methodology implemented under this subsection | ||||||
14 | shall not include
those costs referred to in Sections | ||||||
15 | 1886(d)(5)(B) and 1886(h) of the Social
Security Act. The | ||||||
16 | additional payment amounts required under Section
| ||||||
17 | 1886(d)(5)(F) of the Social Security Act, for hospitals serving | ||||||
18 | a
disproportionate share of low-income or indigent patients, | ||||||
19 | are not required
under this Section. For hospital inpatient | ||||||
20 | services rendered on or after July
1, 1995, the Illinois | ||||||
21 | Department shall
reimburse hospitals using the relative | ||||||
22 | weighting factors and the base payment
rates calculated for | ||||||
23 | each hospital that were in effect on June 30, 1995, less
the | ||||||
24 | portion of such rates attributed by the Illinois Department to | ||||||
25 | the cost of
medical education.
| ||||||
26 | (1) The weighting factors established under Section |
| |||||||
| |||||||
1 | 1886(d)(4) of the
Social Security Act shall not be used in | ||||||
2 | the reimbursement system
established under this Section. | ||||||
3 | Rather, the Illinois Department shall
establish by rule | ||||||
4 | Medicaid weighting factors to be used in the reimbursement
| ||||||
5 | system established under this Section.
| ||||||
6 | (2) The Illinois Department shall define by rule those | ||||||
7 | hospitals or
distinct parts of hospitals that shall be | ||||||
8 | exempt from the reimbursement
system established under | ||||||
9 | this Section. In defining such hospitals, the
Illinois | ||||||
10 | Department shall take into consideration those hospitals | ||||||
11 | exempt
from the Medicare Prospective Payment System as of | ||||||
12 | September 1, 1991. For
hospitals defined as exempt under | ||||||
13 | this subsection, the Illinois Department
shall by rule | ||||||
14 | establish a reimbursement system for payment of inpatient
| ||||||
15 | hospital services rendered on and after September 1, 1991. | ||||||
16 | For all
hospitals that are children's hospitals as defined | ||||||
17 | in Section 5-5.02 of
this Code, the reimbursement | ||||||
18 | methodology shall, through June 30, 1992, net
of all | ||||||
19 | applicable fees, at least equal each children's hospital | ||||||
20 | 1990 ICARE
payment rates, indexed to the current year by | ||||||
21 | application of the DRI hospital
cost index from 1989 to the | ||||||
22 | year in which payments are made. Excepting county
providers | ||||||
23 | as defined in Article XV of this Code, hospitals licensed | ||||||
24 | under the
University of Illinois Hospital Act, and | ||||||
25 | facilities operated by the
Department of Mental Health and | ||||||
26 | Developmental Disabilities (or its successor,
the |
| |||||||
| |||||||
1 | Department of Human Services) for hospital inpatient | ||||||
2 | services rendered on
or after July 1, 1995, the Illinois | ||||||
3 | Department shall reimburse children's
hospitals, as | ||||||
4 | defined in 89 Illinois Administrative Code Section | ||||||
5 | 149.50(c)(3),
at the rates in effect on June 30, 1995, and | ||||||
6 | shall reimburse all other
hospitals at the rates in effect | ||||||
7 | on June 30, 1995, less the portion of such
rates attributed | ||||||
8 | by the Illinois Department to the cost of medical | ||||||
9 | education.
For inpatient hospital services provided on or | ||||||
10 | after August 1, 1998, the
Illinois Department may establish | ||||||
11 | by rule a means of adjusting the rates of
children's | ||||||
12 | hospitals, as defined in 89 Illinois Administrative Code | ||||||
13 | Section
149.50(c)(3), that did not meet that definition on | ||||||
14 | June 30, 1995, in order
for the inpatient hospital rates of | ||||||
15 | such hospitals to take into account the
average inpatient | ||||||
16 | hospital rates of those children's hospitals that did meet
| ||||||
17 | the definition of children's hospitals on June 30, 1995.
| ||||||
18 | (3) (Blank)
| ||||||
19 | (4) Notwithstanding any other provision of this | ||||||
20 | Section, hospitals
that on August 31, 1991, have a contract | ||||||
21 | with the Illinois Department under
Section 3-4 of the | ||||||
22 | Illinois Health Finance Reform Act may elect to continue
to | ||||||
23 | be reimbursed at rates stated in such contracts for general | ||||||
24 | and specialty
care.
| ||||||
25 | (5) In addition to any payments made under this | ||||||
26 | subsection (a), the
Illinois Department shall make the |
| |||||||
| |||||||
1 | adjustment payments required by Section
5-5.02 of this | ||||||
2 | Code; provided, that in the case of any hospital reimbursed
| ||||||
3 | under a per case methodology, the Illinois Department shall | ||||||
4 | add an amount
equal to the product of the hospital's | ||||||
5 | average length of stay, less one
day, multiplied by 20, for | ||||||
6 | inpatient hospital services rendered on or
after September | ||||||
7 | 1, 1991 and on or before September 30, 1992.
| ||||||
8 | (b) (Blank)
| ||||||
9 | (b-3) Potentially preventable readmissions. | ||||||
10 | (1) For fee for service discharges occurring on or | ||||||
11 | after July 1, 2011, or on such later date as determined by | ||||||
12 | rule, the Illinois Department may establish, by rule, a | ||||||
13 | means of adjusting the rates of payment to hospitals that | ||||||
14 | have an excess number of medical assistance readmissions as | ||||||
15 | defined in accordance with the criteria set forth in | ||||||
16 | paragraph (3) of this subsection, as determined by a risk | ||||||
17 | adjusted comparison of the actual and expected number of | ||||||
18 | readmissions in a hospital as described in paragraph (4) of | ||||||
19 | this subsection, in accordance with paragraph (5) of this | ||||||
20 | subsection. It is intended that the rate adjustment under | ||||||
21 | this subsection, when combined with savings attributable | ||||||
22 | to a reduction in readmissions, shall not result in an | ||||||
23 | aggregate annual savings in excess of $40,000,000, | ||||||
24 | relative to the base year. In developing any rules under | ||||||
25 | this subsection, the Department shall consult with a | ||||||
26 | statewide association that represents hospitals in all |
| |||||||
| |||||||
1 | areas of the State. | ||||||
2 | (2) Definitions. For purposes of this subsection: | ||||||
3 | (A) "Potentially preventable readmission" or "PPR" | ||||||
4 | means a readmission to a hospital that follows a prior | ||||||
5 | discharge from a hospital within a period to be defined | ||||||
6 | by rule, but not to exceed 30 days, and that is | ||||||
7 | clinically-related to the prior hospital admission. | ||||||
8 | (B) "Observed rate of readmission" means the | ||||||
9 | number of admissions in each hospital that were | ||||||
10 | actually followed by at least one PPR divided by the | ||||||
11 | total number of admissions. | ||||||
12 | (C) "Expected rate of readmission" means a risk | ||||||
13 | adjusted rate for each hospital that accounts for the | ||||||
14 | severity of illness and age of patients at the time of | ||||||
15 | discharge preceding the readmission. | ||||||
16 | (D) "Excess rate of readmission" means the | ||||||
17 | difference between the observed rates of potentially | ||||||
18 | preventable readmissions and the expected rate of | ||||||
19 | potentially preventable readmissions for each | ||||||
20 | hospital. | ||||||
21 | (E) "Behavioral health" means an admission that | ||||||
22 | includes a primary diagnosis of a major mental health | ||||||
23 | related condition, including, but not limited to, | ||||||
24 | chemical dependency and substance abuse. | ||||||
25 | (3) Readmission criteria. | ||||||
26 | (A) A readmission is a return hospitalization |
| |||||||
| |||||||
1 | following a prior discharge that meets all of the | ||||||
2 | following criteria: | ||||||
3 | (i) The readmission could reasonably have been | ||||||
4 | prevented by the provision of appropriate care | ||||||
5 | consistent with accepted standards in the prior | ||||||
6 | discharge or during the post discharge follow-up | ||||||
7 | period. | ||||||
8 | (ii) The readmission is for a condition or | ||||||
9 | procedure related to the care during the prior | ||||||
10 | discharge or the care during the period | ||||||
11 | immediately following the prior discharge and | ||||||
12 | including, but not limited to, the following: | ||||||
13 | (aa) The same or closely related condition | ||||||
14 | or procedure as the prior discharge. | ||||||
15 | (bb) An infection or other complication of | ||||||
16 | care. | ||||||
17 | (cc) A condition or procedure indicative | ||||||
18 | of a failed
surgical intervention. | ||||||
19 | (dd) An acute decompensation of a | ||||||
20 | coexisting chronic
disease. | ||||||
21 | (B) Readmissions, for the purposes of determining | ||||||
22 | PPRs, excludes circumstances that include, but are not | ||||||
23 | limited to, the following: | ||||||
24 | (i) The original discharge was a | ||||||
25 | patient-initiated discharge and was Against | ||||||
26 | Medical Advice (AMA) and the circumstances of such |
| |||||||
| |||||||
1 | discharge and readmission are documented in the | ||||||
2 | patient's medical record. | ||||||
3 | (ii) The original discharge was for the | ||||||
4 | purpose of securing treatment of a major or | ||||||
5 | metastatic malignancy, multiple trauma, human | ||||||
6 | immunodeficiency virus/acquired immune deficiency | ||||||
7 | syndrome (HIV/AIDS), injuries resulting from | ||||||
8 | violence, attempted suicide, transplants, multiple | ||||||
9 | complex clinical conditions, burns, neonatal, or | ||||||
10 | obstetrical admissions. | ||||||
11 | (iii) The readmission was a planned | ||||||
12 | readmission. | ||||||
13 | (iv) The original discharge resulted in the | ||||||
14 | patient being transferred to another acute care | ||||||
15 | hospital. | ||||||
16 | (4) Methodology. | ||||||
17 | (A) Rate adjustments for each hospital shall be | ||||||
18 | based on such hospital's Medicaid paid claims data for | ||||||
19 | discharges that occurred between July 1, 2008 and June | ||||||
20 | 30, 2009, hereinafter referred to as the base year. The | ||||||
21 | Department shall complete an analysis of each | ||||||
22 | hospital's potentially preventable readmissions in | ||||||
23 | this base year and provide the results confidentially, | ||||||
24 | including patient specific data, to each hospital free | ||||||
25 | of charge at least 90 days prior to the effective date | ||||||
26 | of any rate adjustments under this subsection. |
| |||||||
| |||||||
1 | (B) For each hospital, the Department shall | ||||||
2 | calculate its observed rate of PPRs in the base year | ||||||
3 | and its expected rate of PPRs for the rate year | ||||||
4 | separately for behavioral health PPRs and all other | ||||||
5 | PPRs. The expected rate of PPRs shall be calculated for | ||||||
6 | the rate year, so that achieving the expected rate of | ||||||
7 | PPRs would result in an aggregate savings of | ||||||
8 | $40,000,000 annually, relative to the base year. | ||||||
9 | (C) Excess readmission rates are calculated based | ||||||
10 | on the difference between the observed rate of PPRs in | ||||||
11 | the rate year and the expected rate of PPRs for each | ||||||
12 | hospital. This rate shall be calculated separately for | ||||||
13 | behavioral health PPRs and all other PPRs. In the event | ||||||
14 | the observed rate of PPRs for a hospital is lower than | ||||||
15 | the expected rate of PPRs for that hospital, the excess | ||||||
16 | number of readmissions shall be set at zero. | ||||||
17 | (D) In the event the observed rate of PPRs for | ||||||
18 | hospitals in the aggregate in the rate year is lower | ||||||
19 | than the expected rate of PPRs, the aggregate annual | ||||||
20 | savings in excess of $40,000,000 shall be identified | ||||||
21 | and such amount shall be used only for programs to | ||||||
22 | improve care coordination or to preserve or enhance | ||||||
23 | behavioral health services. | ||||||
24 | (5) Payment Calculation.
If the aggregate annual | ||||||
25 | savings attributable to a reduction in PPRs is less than | ||||||
26 | $40,000,000, each hospital with excess readmissions as |
| |||||||
| |||||||
1 | identified in subparagraph (c) of paragraph (4) of this | ||||||
2 | subsection shall have its payment rate adjusted by a | ||||||
3 | readmission adjustment factor in order to achieve the | ||||||
4 | $40,000,000 in aggregate savings. This adjustment may be | ||||||
5 | made on a quarterly basis. In no event shall the | ||||||
6 | application of the readmission adjustment factor to a | ||||||
7 | hospital result in an annual savings attributable to a | ||||||
8 | reduction in readmissions of more than 2% of the hospital's | ||||||
9 | total annual payments under this Code for inpatient | ||||||
10 | services. | ||||||
11 | (6) Reporting.
On a quarterly basis, the Department | ||||||
12 | shall issue a report free of charge to each hospital that | ||||||
13 | includes, but is not limited to, its observed rate of PPRs, | ||||||
14 | its expected rate of PPRs, and its readmission adjustment | ||||||
15 | factor for prior quarters. The Department shall also | ||||||
16 | provide such information on a quarterly basis for all | ||||||
17 | hospitals free of charge to a statewide association that | ||||||
18 | represents hospitals located in all areas of the State. | ||||||
19 | (b-5) Excepting county providers as defined in Article XV | ||||||
20 | of this Code,
hospitals licensed under the University of | ||||||
21 | Illinois Hospital Act, and
facilities operated by the Illinois | ||||||
22 | Department of Mental Health and
Developmental Disabilities (or | ||||||
23 | its successor, the Department of Human
Services), for | ||||||
24 | outpatient services rendered on or after July 1, 1995
and | ||||||
25 | before July 1, 1998 the Illinois Department shall reimburse
| ||||||
26 | children's hospitals, as defined in the Illinois |
| |||||||
| |||||||
1 | Administrative Code
Section 149.50(c)(3), at the rates in | ||||||
2 | effect on June 30, 1995, less that
portion of such rates | ||||||
3 | attributed by the Illinois Department to the outpatient
| ||||||
4 | indigent volume adjustment and shall reimburse all other | ||||||
5 | hospitals at the rates
in effect on June 30, 1995, less the | ||||||
6 | portions of such rates attributed by the
Illinois Department to | ||||||
7 | the cost of medical education and attributed by the
Illinois | ||||||
8 | Department to the outpatient indigent volume adjustment. For
| ||||||
9 | outpatient services provided on or after July 1, 1998, | ||||||
10 | reimbursement rates
shall be established by rule.
| ||||||
11 | (c) In addition to any other payments under this Code, the | ||||||
12 | Illinois
Department shall develop a hospital disproportionate | ||||||
13 | share reimbursement
methodology that, effective July 1, 1991, | ||||||
14 | through September 30, 1992,
shall reimburse hospitals | ||||||
15 | sufficiently to expend the fee monies described
in subsection | ||||||
16 | (b) of Section 14-3 of this Code and the federal matching
funds | ||||||
17 | received by the Illinois Department as a result of expenditures | ||||||
18 | made
by the Illinois Department as required by this subsection | ||||||
19 | (c) and Section
14-2 that are attributable to fee monies | ||||||
20 | deposited in the Fund, less
amounts applied to adjustment | ||||||
21 | payments under Section 5-5.02.
| ||||||
22 | (d) Critical Care Access Payments.
| ||||||
23 | (1) In addition to any other payments made under this | ||||||
24 | Code,
the Illinois Department shall develop a | ||||||
25 | reimbursement methodology that shall
reimburse Critical | ||||||
26 | Care Access Hospitals for the specialized services that
|
| |||||||
| |||||||
1 | qualify them as Critical Care Access Hospitals. No | ||||||
2 | adjustment payments shall be
made under this subsection on | ||||||
3 | or after July 1, 1995.
| ||||||
4 | (2) "Critical Care Access Hospitals" includes, but is | ||||||
5 | not limited to,
hospitals that meet at least one of the | ||||||
6 | following criteria:
| ||||||
7 | (A) Hospitals located outside of a metropolitan | ||||||
8 | statistical area that
are designated as Level II | ||||||
9 | Perinatal Centers and that provide a
disproportionate | ||||||
10 | share of perinatal services to recipients; or
| ||||||
11 | (B) Hospitals that are designated as Level I Trauma | ||||||
12 | Centers (adult
or pediatric) and certain Level II | ||||||
13 | Trauma Centers as determined by the
Illinois | ||||||
14 | Department; or
| ||||||
15 | (C) Hospitals located outside of a metropolitan | ||||||
16 | statistical area and
that provide a disproportionate | ||||||
17 | share of obstetrical services to recipients.
| ||||||
18 | (e) Inpatient high volume adjustment. For hospital | ||||||
19 | inpatient services,
effective with rate periods beginning on or | ||||||
20 | after October 1, 1993, in
addition to rates paid for inpatient | ||||||
21 | services by the Illinois Department, the
Illinois Department | ||||||
22 | shall make adjustment payments for inpatient services
| ||||||
23 | furnished by Medicaid high volume hospitals. The Illinois | ||||||
24 | Department shall
establish by rule criteria for qualifying as a | ||||||
25 | Medicaid high volume hospital
and shall establish by rule a | ||||||
26 | reimbursement methodology for calculating these
adjustment |
| |||||||
| |||||||
1 | payments to Medicaid high volume hospitals. No adjustment | ||||||
2 | payment
shall be made under this subsection for services | ||||||
3 | rendered on or after July 1,
1995.
| ||||||
4 | (f) The Illinois Department shall modify its current rules | ||||||
5 | governing
adjustment payments for targeted access, critical | ||||||
6 | care access, and
uncompensated care to classify those | ||||||
7 | adjustment payments as not being payments
to disproportionate | ||||||
8 | share hospitals under Title XIX of the federal Social
Security | ||||||
9 | Act. Rules adopted under this subsection shall not be effective | ||||||
10 | with
respect to services rendered on or after July 1, 1995. The | ||||||
11 | Illinois Department
has no obligation to adopt or implement any | ||||||
12 | rules or make any payments under
this subsection for services | ||||||
13 | rendered on or after July 1, 1995.
| ||||||
14 | (f-5) The State recognizes that adjustment payments to | ||||||
15 | hospitals providing
certain services or incurring certain | ||||||
16 | costs may be necessary to assure that
recipients of medical | ||||||
17 | assistance have adequate access to necessary medical
services. | ||||||
18 | These adjustments include payments for teaching costs and
| ||||||
19 | uncompensated care, trauma center payments, rehabilitation | ||||||
20 | hospital payments,
perinatal center payments, obstetrical care | ||||||
21 | payments, targeted access payments,
Medicaid high volume | ||||||
22 | payments, and outpatient indigent volume payments. On or
before | ||||||
23 | April 1, 1995, the Illinois Department shall issue | ||||||
24 | recommendations
regarding (i) reimbursement mechanisms or | ||||||
25 | adjustment payments to reflect these
costs and services, | ||||||
26 | including methods by which the payments may be calculated
and |
| |||||||
| |||||||
1 | the method by which the payments may be financed, and (ii) | ||||||
2 | reimbursement
mechanisms or adjustment payments to reflect | ||||||
3 | costs and services of federally
qualified health centers with | ||||||
4 | respect to recipients of medical assistance.
| ||||||
5 | (g) If one or more hospitals file suit in any court | ||||||
6 | challenging any part of
this Article XIV, payments to hospitals | ||||||
7 | under this Article XIV shall be made
only to the extent that | ||||||
8 | sufficient monies are available in the Fund and only to
the | ||||||
9 | extent that any monies in the Fund are not prohibited from | ||||||
10 | disbursement
under any order of the court.
| ||||||
11 | (h) Payments under the disbursement methodology described | ||||||
12 | in this Section
are subject to approval by the federal | ||||||
13 | government in an appropriate State plan
amendment.
| ||||||
14 | (i) The Illinois Department may by rule establish criteria | ||||||
15 | for and develop
methodologies for adjustment payments to | ||||||
16 | hospitals participating under this
Article.
| ||||||
17 | (j) Hospital Residing Long Term Care Services. In addition | ||||||
18 | to any other
payments made under this Code, the Illinois | ||||||
19 | Department may by rule establish
criteria and develop | ||||||
20 | methodologies for payments to hospitals for Hospital
Residing | ||||||
21 | Long Term Care Services.
| ||||||
22 | (k) Critical Access Hospital outpatient payments. In | ||||||
23 | addition to any other payments authorized under this Code, the | ||||||
24 | Illinois Department shall reimburse critical access hospitals, | ||||||
25 | as designated by the Illinois Department of Public Health in | ||||||
26 | accordance with 42 CFR 485, Subpart F, for outpatient services |
| |||||||
| |||||||
1 | at an amount that is no less than the cost of providing such | ||||||
2 | services, based on Medicare cost principles. Payments under | ||||||
3 | this subsection shall be subject to appropriation. | ||||||
4 | (Source: P.A. 96-1382, eff. 1-1-11.)
| ||||||
5 | Section 20. The Senior Citizens and Disabled Persons | ||||||
6 | Property Tax Relief and Pharmaceutical Assistance Act is | ||||||
7 | amended by changing Section 4 as follows:
| ||||||
8 | (320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
| ||||||
9 | Sec. 4. Amount of Grant.
| ||||||
10 | (a) In general. Any individual 65 years or older or any | ||||||
11 | individual who will
become 65 years old during the calendar | ||||||
12 | year in which a claim is filed, and any
surviving spouse of | ||||||
13 | such a claimant, who at the time of death received or was
| ||||||
14 | entitled to receive a grant pursuant to this Section, which | ||||||
15 | surviving spouse
will become 65 years of age within the 24 | ||||||
16 | months immediately following the
death of such claimant and | ||||||
17 | which surviving spouse but for his or her age is
otherwise | ||||||
18 | qualified to receive a grant pursuant to this Section, and any
| ||||||
19 | disabled person whose annual household income is less than the | ||||||
20 | income eligibility limitation, as defined in subsection (a-5)
| ||||||
21 | and whose household is liable for payment of property taxes | ||||||
22 | accrued or has
paid rent constituting property taxes accrued | ||||||
23 | and is domiciled in this State
at the time he or she files his | ||||||
24 | or her claim is entitled to claim a
grant under this Act.
With |
| |||||||
| |||||||
1 | respect to claims filed by individuals who will become 65 years | ||||||
2 | old
during the calendar year in which a claim is filed, the | ||||||
3 | amount of any grant
to which that household is entitled shall | ||||||
4 | be an amount equal to 1/12 of the
amount to which the claimant | ||||||
5 | would otherwise be entitled as provided in
this Section, | ||||||
6 | multiplied by the number of months in which the claimant was
65 | ||||||
7 | in the calendar year in which the claim is filed.
| ||||||
8 | (a-5) Income eligibility limitation. For purposes of this | ||||||
9 | Section, "income eligibility limitation" means an amount for | ||||||
10 | grant years 2008 and thereafter: | ||||||
11 | (1) less than $22,218 for a household containing one | ||||||
12 | person; | ||||||
13 | (2) less than $29,480 for a household containing 2 | ||||||
14 | persons; or | ||||||
15 | (3) less than $36,740 for a
household containing 3 or | ||||||
16 | more persons. | ||||||
17 | For 2009 claim year applications submitted during calendar | ||||||
18 | year 2010, a household must have annual household income of | ||||||
19 | less than $27,610 for a household containing one person; less | ||||||
20 | than $36,635 for a household containing 2 persons; or less than | ||||||
21 | $45,657 for a household containing 3 or more persons. | ||||||
22 | The Department on Aging may adopt rules such that on | ||||||
23 | January 1, 2011, and thereafter, the foregoing household income | ||||||
24 | eligibility limits may be changed to reflect the annual cost of | ||||||
25 | living adjustment in Social Security and Supplemental Security | ||||||
26 | Income benefits that are applicable to the year for which those |
| |||||||
| |||||||
1 | benefits are being reported as income on an application. | ||||||
2 | If a person files as a surviving spouse, then only his or | ||||||
3 | her income shall be counted in determining his or her household | ||||||
4 | income. | ||||||
5 | (b) Limitation. Except as otherwise provided in | ||||||
6 | subsections (a) and (f)
of this Section, the maximum amount of | ||||||
7 | grant which a claimant is
entitled to claim is the amount by | ||||||
8 | which the property taxes accrued which
were paid or payable | ||||||
9 | during the last preceding tax year or rent
constituting | ||||||
10 | property taxes accrued upon the claimant's residence for the
| ||||||
11 | last preceding taxable year exceeds 3 1/2% of the claimant's | ||||||
12 | household
income for that year but in no event is the grant to | ||||||
13 | exceed (i) $700 less
4.5% of household income for that year for | ||||||
14 | those with a household income of
$14,000 or less or (ii) $70 if | ||||||
15 | household income for that year is more than
$14,000.
| ||||||
16 | (c) Public aid recipients. If household income in one or | ||||||
17 | more
months during a year includes cash assistance in excess of | ||||||
18 | $55 per month
from the Department of Healthcare and Family | ||||||
19 | Services or the Department of Human Services (acting
as | ||||||
20 | successor to the Department of Public Aid under the Department | ||||||
21 | of Human
Services Act) which was determined under regulations | ||||||
22 | of
that Department on a measure of need that included an | ||||||
23 | allowance for actual
rent or property taxes paid by the | ||||||
24 | recipient of that assistance, the amount
of grant to which that | ||||||
25 | household is entitled, except as otherwise provided in
| ||||||
26 | subsection (a), shall be the product of (1) the maximum amount |
| |||||||
| |||||||
1 | computed as
specified in subsection (b) of this Section and (2) | ||||||
2 | the ratio of the number of
months in which household income did | ||||||
3 | not include such cash assistance over $55
to the number twelve. | ||||||
4 | If household income did not include such cash assistance
over | ||||||
5 | $55 for any months during the year, the amount of the grant to | ||||||
6 | which the
household is entitled shall be the maximum amount | ||||||
7 | computed as specified in
subsection (b) of this Section. For | ||||||
8 | purposes of this paragraph (c), "cash
assistance" does not | ||||||
9 | include any amount received under the federal Supplemental
| ||||||
10 | Security Income (SSI) program.
| ||||||
11 | (d) Joint ownership. If title to the residence is held | ||||||
12 | jointly by
the claimant with a person who is not a member of | ||||||
13 | his or her household,
the amount of property taxes accrued used | ||||||
14 | in computing the amount of grant
to which he or she is entitled | ||||||
15 | shall be the same percentage of property
taxes accrued as is | ||||||
16 | the percentage of ownership held by the claimant in the
| ||||||
17 | residence.
| ||||||
18 | (e) More than one residence. If a claimant has occupied | ||||||
19 | more than
one residence in the taxable year, he or she may | ||||||
20 | claim only one residence
for any part of a month. In the case | ||||||
21 | of property taxes accrued, he or she
shall prorate 1/12 of the | ||||||
22 | total property taxes accrued on
his or her residence to each | ||||||
23 | month that he or she owned and occupied
that residence; and, in | ||||||
24 | the case of rent constituting property taxes accrued,
shall | ||||||
25 | prorate each month's rent payments to the residence
actually | ||||||
26 | occupied during that month.
|
| |||||||
| |||||||
1 | (f) (Blank).
| ||||||
2 | (g) Effective January 1, 2006, there is hereby established | ||||||
3 | a program of pharmaceutical assistance to the aged and | ||||||
4 | disabled, entitled the Illinois Seniors and Disabled Drug | ||||||
5 | Coverage Program, which shall be administered by the Department | ||||||
6 | of Healthcare and Family Services and the Department on Aging | ||||||
7 | in accordance with this subsection, to consist of coverage of | ||||||
8 | specified prescription drugs on behalf of beneficiaries of the | ||||||
9 | program as set forth in this subsection. | ||||||
10 | To become a beneficiary under the program established under | ||||||
11 | this subsection, a person must: | ||||||
12 | (1) be (i) 65 years of age or older or (ii) disabled; | ||||||
13 | and | ||||||
14 | (2) be domiciled in this State; and | ||||||
15 | (3) enroll with a qualified Medicare Part D | ||||||
16 | Prescription Drug Plan if eligible and apply for all | ||||||
17 | available subsidies under Medicare Part D; and | ||||||
18 | (4) for the 2006 and 2007 claim years, have a maximum | ||||||
19 | household income of (i) less than $21,218 for a household | ||||||
20 | containing one person, (ii) less than $28,480 for a | ||||||
21 | household containing 2 persons, or (iii) less than $35,740 | ||||||
22 | for a household containing 3 or more persons; and | ||||||
23 | (5) for the 2008 claim year, have a maximum household | ||||||
24 | income of (i) less than $22,218 for a household containing | ||||||
25 | one person, (ii) $29,480 for a household containing 2 | ||||||
26 | persons, or (iii) $36,740 for a household containing 3 or |
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1 | more persons; and | ||||||
2 | (6) for 2009 claim year applications submitted during | ||||||
3 | calendar year 2010, have annual household income of less | ||||||
4 | than (i) $27,610 for a household containing one person; | ||||||
5 | (ii) less than $36,635 for a household containing 2 | ||||||
6 | persons; or (iii) less than $45,657 for a household | ||||||
7 | containing 3 or more persons ; and . | ||||||
8 | (7) as of September 1, 2011, have a maximum household | ||||||
9 | income at or below 200% of the federal poverty level. | ||||||
10 | The Department of Healthcare and Family Services may adopt | ||||||
11 | rules such that on January 1, 2011, and thereafter, the | ||||||
12 | foregoing household income eligibility limits may be changed to | ||||||
13 | reflect the annual cost of living adjustment in Social Security | ||||||
14 | and Supplemental Security Income benefits that are applicable | ||||||
15 | to the year for which those benefits are being reported as | ||||||
16 | income on an application. | ||||||
17 | All individuals enrolled as of December 31, 2005, in the | ||||||
18 | pharmaceutical assistance program operated pursuant to | ||||||
19 | subsection (f) of this Section and all individuals enrolled as | ||||||
20 | of December 31, 2005, in the SeniorCare Medicaid waiver program | ||||||
21 | operated pursuant to Section 5-5.12a of the Illinois Public Aid | ||||||
22 | Code shall be automatically enrolled in the program established | ||||||
23 | by this subsection for the first year of operation without the | ||||||
24 | need for further application, except that they must apply for | ||||||
25 | Medicare Part D and the Low Income Subsidy under Medicare Part | ||||||
26 | D. A person enrolled in the pharmaceutical assistance program |
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1 | operated pursuant to subsection (f) of this Section as of | ||||||
2 | December 31, 2005, shall not lose eligibility in future years | ||||||
3 | due only to the fact that they have not reached the age of 65. | ||||||
4 | To the extent permitted by federal law, the Department may | ||||||
5 | act as an authorized representative of a beneficiary in order | ||||||
6 | to enroll the beneficiary in a Medicare Part D Prescription | ||||||
7 | Drug Plan if the beneficiary has failed to choose a plan and, | ||||||
8 | where possible, to enroll beneficiaries in the low-income | ||||||
9 | subsidy program under Medicare Part D or assist them in | ||||||
10 | enrolling in that program. | ||||||
11 | Beneficiaries under the program established under this | ||||||
12 | subsection shall be divided into the following 4 eligibility | ||||||
13 | groups: | ||||||
14 | (A) Eligibility Group 1 shall consist of beneficiaries | ||||||
15 | who are not eligible for Medicare Part D coverage and who
| ||||||
16 | are: | ||||||
17 | (i) disabled and under age 65; or | ||||||
18 | (ii) age 65 or older, with incomes over 200% of the | ||||||
19 | Federal Poverty Level; or | ||||||
20 | (iii) age 65 or older, with incomes at or below | ||||||
21 | 200% of the Federal Poverty Level and not eligible for | ||||||
22 | federally funded means-tested benefits due to | ||||||
23 | immigration status. | ||||||
24 | (B) Eligibility Group 2 shall consist of beneficiaries | ||||||
25 | who are eligible for Medicare Part D coverage. | ||||||
26 | (C) Eligibility Group 3 shall consist of beneficiaries |
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1 | age 65 or older, with incomes at or below 200% of the | ||||||
2 | Federal Poverty Level, who are not barred from receiving | ||||||
3 | federally funded means-tested benefits due to immigration | ||||||
4 | status and are not eligible for Medicare Part D coverage. | ||||||
5 | If the State applies and receives federal approval for | ||||||
6 | a waiver under Title XIX of the Social Security Act, | ||||||
7 | persons in Eligibility Group 3 shall continue to receive | ||||||
8 | benefits through the approved waiver, and Eligibility | ||||||
9 | Group 3 may be expanded to include disabled persons under | ||||||
10 | age 65 with incomes under 200% of the Federal Poverty Level | ||||||
11 | who are not eligible for Medicare and who are not barred | ||||||
12 | from receiving federally funded means-tested benefits due | ||||||
13 | to immigration status. | ||||||
14 | (D) Eligibility Group 4 shall consist of beneficiaries | ||||||
15 | who are otherwise described in Eligibility Group 2 who have | ||||||
16 | a diagnosis of HIV or AIDS.
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17 | Notwithstanding anything in this paragraph to the | ||||||
18 | contrary, the Department of Healthcare and Family Services may | ||||||
19 | establish by emergency rule changes in cost-sharing necessary | ||||||
20 | to conform the cost of the program to the amounts appropriated | ||||||
21 | for State fiscal year 2012 and future fiscal years. The program | ||||||
22 | established under this subsection shall cover the cost of | ||||||
23 | covered prescription drugs in excess of the beneficiary | ||||||
24 | cost-sharing amounts set forth in this paragraph that are not | ||||||
25 | covered by Medicare. In 2006, beneficiaries shall pay a | ||||||
26 | co-payment of $2 for each prescription of a generic drug and $5 |
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1 | for each prescription of a brand-name drug. In future years, | ||||||
2 | beneficiaries shall pay co-payments equal to the co-payments | ||||||
3 | required under Medicare Part D for "other low-income subsidy | ||||||
4 | eligible individuals" pursuant to 42 CFR 423.782(b). For | ||||||
5 | individuals in Eligibility Groups 1, 2, and 3, once the program | ||||||
6 | established under this subsection and Medicare combined have | ||||||
7 | paid $1,750 in a year for covered prescription drugs, the | ||||||
8 | beneficiary shall pay 20% of the cost of each prescription in | ||||||
9 | addition to the co-payments set forth in this paragraph. For | ||||||
10 | individuals in Eligibility Group 4, once the program | ||||||
11 | established under this subsection and Medicare combined have | ||||||
12 | paid $1,750 in a year for covered prescription drugs, the | ||||||
13 | beneficiary shall pay 20% of the cost of each prescription in | ||||||
14 | addition to the co-payments set forth in this paragraph unless | ||||||
15 | the drug is included in the formulary of the Illinois AIDS Drug | ||||||
16 | Assistance Program operated by the Illinois Department of | ||||||
17 | Public Health and covered by the Medicare Part D Prescription | ||||||
18 | Drug Plan in which the beneficiary is enrolled. If the drug is | ||||||
19 | included in the formulary of the Illinois AIDS Drug Assistance | ||||||
20 | Program and covered by the Medicare Part D Prescription Drug | ||||||
21 | Plan in which the beneficiary is enrolled, individuals in | ||||||
22 | Eligibility Group 4 shall continue to pay the co-payments set | ||||||
23 | forth in this paragraph after the program established under | ||||||
24 | this subsection and Medicare combined have paid $1,750 in a | ||||||
25 | year for covered prescription drugs.
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26 | For beneficiaries eligible for Medicare Part D coverage, |
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1 | the program established under this subsection shall pay 100% of | ||||||
2 | the premiums charged by a qualified Medicare Part D | ||||||
3 | Prescription Drug Plan for Medicare Part D basic prescription | ||||||
4 | drug coverage, not including any late enrollment penalties. | ||||||
5 | Qualified Medicare Part D Prescription Drug Plans may be | ||||||
6 | limited by the Department of Healthcare and Family Services to | ||||||
7 | those plans that sign a coordination agreement with the | ||||||
8 | Department. | ||||||
9 | For Notwithstanding Section 3.15, for purposes of the | ||||||
10 | program established under this subsection, the term "covered | ||||||
11 | prescription drug" has the following meanings: | ||||||
12 | For Eligibility Group 1, "covered prescription drug" | ||||||
13 | means: (1) any cardiovascular agent or drug; (2) any | ||||||
14 | insulin or other prescription drug used in the treatment of | ||||||
15 | diabetes, including syringe and needles used to administer | ||||||
16 | the insulin; (3) any prescription drug used in the | ||||||
17 | treatment of arthritis; (4) any prescription drug used in | ||||||
18 | the treatment of cancer; (5) any prescription drug used in | ||||||
19 | the treatment of Alzheimer's disease; (6) any prescription | ||||||
20 | drug used in the treatment of Parkinson's disease; (7) any | ||||||
21 | prescription drug used in the treatment of glaucoma; (8) | ||||||
22 | any prescription drug used in the treatment of lung disease | ||||||
23 | and smoking-related illnesses; (9) any prescription drug | ||||||
24 | used in the treatment of osteoporosis; and (10) any | ||||||
25 | prescription drug used in the treatment of multiple | ||||||
26 | sclerosis. The Department may add additional therapeutic |
| |||||||
| |||||||
1 | classes by rule. The Department may adopt a preferred drug | ||||||
2 | list within any of the classes of drugs described in items | ||||||
3 | (1) through (10) of this paragraph. The specific drugs or | ||||||
4 | therapeutic classes of covered prescription drugs shall be | ||||||
5 | indicated by rule. | ||||||
6 | For Eligibility Group 2, "covered prescription drug" | ||||||
7 | means those drugs covered by the Medicare Part D | ||||||
8 | Prescription Drug Plan in which the beneficiary is | ||||||
9 | enrolled. | ||||||
10 | For Eligibility Group 3, "covered prescription drug" | ||||||
11 | means those drugs covered by the Medical Assistance Program | ||||||
12 | under Article V of the Illinois Public Aid Code. | ||||||
13 | For Eligibility Group 4, "covered prescription drug" | ||||||
14 | means those drugs covered by the Medicare Part D | ||||||
15 | Prescription Drug Plan in which the beneficiary is | ||||||
16 | enrolled. | ||||||
17 | An individual in Eligibility Group 1, 2, 3, or 4 may opt to | ||||||
18 | receive a $25 monthly payment in lieu of the direct coverage | ||||||
19 | described in this subsection. | ||||||
20 | Any person otherwise eligible for pharmaceutical | ||||||
21 | assistance under this subsection whose covered drugs are | ||||||
22 | covered by any public program is ineligible for assistance | ||||||
23 | under this subsection to the extent that the cost of those | ||||||
24 | drugs is covered by the other program. | ||||||
25 | The Department of Healthcare and Family Services shall | ||||||
26 | establish by rule the methods by which it will provide for the |
| |||||||
| |||||||
1 | coverage called for in this subsection. Those methods may | ||||||
2 | include direct reimbursement to pharmacies or the payment of a | ||||||
3 | capitated amount to Medicare Part D Prescription Drug Plans. | ||||||
4 | For a pharmacy to be reimbursed under the program | ||||||
5 | established under this subsection, it must comply with rules | ||||||
6 | adopted by the Department of Healthcare and Family Services | ||||||
7 | regarding coordination of benefits with Medicare Part D | ||||||
8 | Prescription Drug Plans. A pharmacy may not charge a | ||||||
9 | Medicare-enrolled beneficiary of the program established under | ||||||
10 | this subsection more for a covered prescription drug than the | ||||||
11 | appropriate Medicare cost-sharing less any payment from or on | ||||||
12 | behalf of the Department of Healthcare and Family Services. | ||||||
13 | The Department of Healthcare and Family Services or the | ||||||
14 | Department on Aging, as appropriate, may adopt rules regarding | ||||||
15 | applications, counting of income, proof of Medicare status, | ||||||
16 | mandatory generic policies, and pharmacy reimbursement rates | ||||||
17 | and any other rules necessary for the cost-efficient operation | ||||||
18 | of the program established under this subsection. | ||||||
19 | (h) A qualified individual is not entitled to duplicate
| ||||||
20 | benefits in a coverage period as a result of the changes made
| ||||||
21 | by this amendatory Act of the 96th General Assembly.
| ||||||
22 | (Source: P.A. 95-208, eff. 8-16-07; 95-644, eff. 10-12-07; | ||||||
23 | 95-876, eff. 8-21-08; 96-804, eff. 1-1-10; revised 9-16-10.)
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24 | Section 99. Effective date. This Act takes effect upon | ||||||
25 | becoming law.".
|