Full Text of SB1802 97th General Assembly
SB1802ham001 97TH GENERAL ASSEMBLY | Rep. Sara Feigenholtz Filed: 5/27/2011
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| 1 | | AMENDMENT TO SENATE BILL 1802
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1802 by replacing | 3 | | everything after the enacting clause with the following:
| 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:
| 16 | | (30 ILCS 540/3-2)
| 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
| 22 | | agency shall pay interest to the vendor in accordance with the | 23 | | following:
| 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
| 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.
| 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
| 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.
| 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.)
| 21 | | Section 10. The Children's Health Insurance Program Act is | 22 | | amended by changing Section 30 as follows:
| 23 | | (215 ILCS 106/30)
| 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:
| 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.
| 8 | | (2) Health insurance premiums for family members, | 9 | | either children or adults, in families whose household
| 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:
| 14 | | (A) $15 per month for one family member.
| 15 | | (B) $25 per month for 2 family members.
| 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.
| 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 .
| 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:
| 4 | | (A) $5 for medical visits.
| 5 | | (B) $3 for generic prescriptions and $5 for brand | 6 | | name
prescriptions.
| 7 | | (C) $25 for emergency room use for a non-emergency
| 8 | | situation as defined by the Department by rule.
| 9 | | (5) (Blank) The maximum amount of out-of-pocket | 10 | | expenses for co-payments shall be
$100 per family per year .
| 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.
| 18 | | (Source: P.A. 94-48, eff. 7-1-05.)
| 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:
| 21 | | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| 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:
| 3 | | 1. Recipients of basic maintenance grants under | 4 | | Articles III and IV.
| 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
| 13 | | necessary medical care, including but not limited to the | 14 | | following:
| 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:
| 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
| 22 | | fiscal year 2001, equal to or less than 85% in | 23 | | fiscal year 2002 and until
a date to be determined | 24 | | by the Department by rule, and equal to or less
| 25 | | than 100% beginning on the date determined by the | 26 | | Department by rule, of the nonfarm income official |
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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
| 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
| 9 | | fiscal year 2001, equal to or less than 85% in | 10 | | fiscal year 2002 and until
a date to be determined | 11 | | by the Department by rule, and equal to or less
| 12 | | than 100% beginning on the date determined by the | 13 | | Department by rule, of the nonfarm income official | 14 | | poverty
line, as defined in item (i) of this | 15 | | subparagraph (a).
| 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
| 22 | | permitted by federal law.
| 23 | | 3. Persons who would otherwise qualify for Aid to the | 24 | | Medically
Indigent under Article VII.
| 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
| 3 | | expenses.
| 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
| 10 | | the maximum extent possible under Title XIX of the
Federal | 11 | | Social Security Act.
| 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
| 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
| 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
| 24 | | eligibility.
| 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
| 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.
| 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.
| 16 | | 7. Persons who are under 21 years of age and would
| 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
| 20 | | Financial Participation, and provided the Illinois | 21 | | Department determines that:
| 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;
| 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;
| 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.
| 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
| 13 | | employment earnings. The plan for coverage for this class | 14 | | of persons shall:
| 15 | | (a) extend the medical assistance coverage for up | 16 | | to 12 months following
termination of basic | 17 | | maintenance assistance; and
| 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:
| 22 | | (i) such coverage shall be pursuant to | 23 | | provisions of the federal
Social Security Act;
| 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
| 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.
| 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.
| 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
| 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.
| 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:
| 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
| 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
| 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.
| 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 |
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| 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 |
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| 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. |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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)
|
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| 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 |
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| 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 |
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| 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
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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.
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| 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.
| 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.
| 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 |
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| 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 |
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| 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.)
| 24 | | Section 99. Effective date. This Act takes effect upon | 25 | | becoming law.".
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