Illinois General Assembly - Full Text of SB1802
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Full Text of SB1802  97th General Assembly


Rep. Sara Feigenholtz

Filed: 5/27/2011





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2    AMENDMENT NO. ______. Amend Senate Bill 1802 by replacing
3everything after the enacting clause with the following:
4    "Section 1. The Department of Human Services Act is amended
5by adding Section 10-66 as follows:
6    (20 ILCS 1305/10-66 new)
7    Sec. 10-66. Rate reductions. For State fiscal year 2012,
8rates for medical services purchased by the Divisions of
9Alcohol and Substance Abuse, Community Health and Prevention,
10Developmentally Disabilities, Mental Health, or Rehabilitation
11Services within the Department of Human Services shall not be
12reduced below the rates calculated on April 1, 2011 unless the
13Department of Human Services promulgates rules and rules are
14implemented authorizing rate reductions.
15    Section 3. The Disabled Persons Rehabilitation Act is



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1amended by adding Section 10a as follows:
2    (20 ILCS 2405/10a new)
3    Sec. 10a. Financial Participation of Students Attending
4the Illinois School for the Deaf and the Illinois School for
5the Visually Impaired.
6    (a) General. The Illinois School for the Deaf and the
7Illinois School for the Visually Impaired are required to
8provide eligible students with disabilities with a free and
9appropriate education. As part of the admission process to
10either school, the Department shall complete a financial
11analysis on each student attending the Illinois School for the
12Deaf or the Illinois School for the Visually Impaired and shall
13ask parents or guardians to participate, if applicable, in the
14cost of identified services or activities that are not
15education related.
16    (b) Completion of financial analysis. Prior to admission,
17and annually thereafter, a financial analysis shall be
18completed on each student attending the Illinois School for the
19Deaf or the Illinois School for the Visually Impaired. If at
20any time there is reason to believe there is a change in the
21student's financial situation that will affect their financial
22participation, 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
11based on income standards developed by the Department, parents
12or guardians of students attending the Illinois School for the
13Deaf or the Illinois School for the Visually Impaired shall be
14asked to financially participate in the following fees for
15services 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
6or Temporary Assistance for Needy Families (TANF) shall not be
7required to financially participate in the fees established in
8this subsection (c).
9    Exceptions may be granted to parents or guardians who are
10unable to meet the financial participation obligations due to
11extenuating circumstances. Requests for exceptions must be
12made in writing and must be submitted to the Director of the
13Division of Rehabilitation Services for review.
14    Section 5. The State Prompt Payment Act is amended by
15changing Section 3-2 as follows:
16    (30 ILCS 540/3-2)
17    Sec. 3-2. Beginning July 1, 1993, in any instance where a
18State official or agency is late in payment of a vendor's bill
19or invoice for goods or services furnished to the State, as
20defined in Section 1, properly approved in accordance with
21rules promulgated under Section 3-3, the State official or
22agency shall pay interest to the vendor in accordance with the
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;
1996-959, eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1501, eff.
201-25-11; 96-1530, eff. 2-16-11; revised 2-22-11.)
21    Section 10. The Children's Health Insurance Program Act is
22amended 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
2to subdivision (a)(2) of Section 25 and persons enrolled in a
3health benefits waiver program pursuant to Section 40 shall be
4subject 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
15insurance plan pursuant to subdivision (a)(1) of Section 25
16shall be subject to the cost sharing provisions as stated in
17the 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
20changing 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
23under this Article shall be available to any of the following
24classes of persons in respect to whom a plan for coverage has



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1been submitted to the Governor by the Illinois Department and
2approved 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
7Department is authorized to adopt only those rules necessary,
8including emergency rules. Nothing in Public Act 96-20 permits
9the Department to adopt rules or issue a decision that expands
10eligibility for the FamilyCare Program to a person whose income
11exceeds 185% of the Federal Poverty Level as determined from
12time to time by the U.S. Department of Health and Human
13Services, unless the Department is provided with express
14statutory authority.
15    The Illinois Department and the Governor shall provide a
16plan for coverage of the persons eligible under paragraph 7 as
17soon as possible after July 1, 1984.
18    The eligibility of any such person for medical assistance
19under this Article is not affected by the payment of any grant
20under the Senior Citizens and Disabled Persons Property Tax
21Relief and Pharmaceutical Assistance Act or any distributions
22or items of income described under subparagraph (X) of
23paragraph (2) of subsection (a) of Section 203 of the Illinois
24Income Tax Act. The Department shall by rule establish the
25amounts of assets to be disregarded in determining eligibility
26for medical assistance, which shall at a minimum equal the



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1amounts to be disregarded under the Federal Supplemental
2Security Income Program. The amount of assets of a single
3person to be disregarded shall not be less than $2,000, and the
4amount of assets of a married couple to be disregarded shall
5not be less than $3,000.
6    To the extent permitted under federal law, any person found
7guilty of a second violation of Article VIIIA shall be
8ineligible for medical assistance under this Article, as
9provided in Section 8A-8.
10    The eligibility of any person for medical assistance under
11this Article shall not be affected by the receipt by the person
12of donations or benefits from fundraisers held for the person
13in cases of serious illness, as long as neither the person nor
14members of the person's family have actual control over the
15donations or benefits or the disbursement of the donations or
17(Source: P.A. 95-546, eff. 8-29-07; 95-1055, eff. 4-10-09;
1896-20, eff. 6-30-09; 96-181, eff. 8-10-09; 96-328, eff.
198-11-09; 96-567, eff. 1-1-10; 96-1000, eff. 7-2-10; 96-1123,
20eff. 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
23that recipients under any Article of this Code shall pay a fee
24as a co-payment for services. Co-payments shall be maximized to
25the extent permitted by federal law. Provided, however, that



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1any such rule must provide that no co-payment requirement can
2exist for renal dialysis, radiation therapy, cancer
3chemotherapy, or insulin, and other products necessary on a
4recurring basis, the absence of which would be life
5threatening, or where co-payment expenditures for required
6services and/or medications for chronic diseases that the
7Illinois Department shall by rule designate shall cause an
8extensive financial burden on the recipient, and provided no
9co-payment shall exist for emergency room encounters which are
10for medical emergencies. The Department shall seek approval of
11a State plan amendment that allows pharmacies to refuse to
12dispense drugs in circumstances where the recipient does not
13pay the required co-payment. In the event the State plan
14amendment is rejected, co-payments may not exceed $3 for brand
15name drugs, $1 for other pharmacy services other than for
16generic drugs, and $2 for physician services, dental services,
17optical services and supplies, chiropractic services, podiatry
18services, and encounter rate clinic services. There shall be no
19co-payment for generic drugs. Co-payments may not exceed $10
20for emergency room use for a non-emergency situation as defined
21by the Department by rule and subject to federal approval.
22Co-payments may not exceed $3 for hospital outpatient and
23clinic 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
3under this Article for prescription drugs provided to a
4recipient of aid under this Article shall include the name of
5the prescriber or an acceptable identification number as
6established by the Department.
7    (b) Pharmacies providing prescription drugs under this
8Article shall be reimbursed at a rate which shall include a
9professional dispensing fee as determined by the Illinois
10Department, plus the current acquisition cost of the
11prescription drug dispensed. The Illinois Department shall
12update its information on the acquisition costs of all
13prescription drugs no less frequently than every 30 days.
14However, the Illinois Department may set the rate of
15reimbursement for the acquisition cost, by rule, at a
16percentage of the current average wholesale acquisition cost.
17    (c) (Blank).
18    (d) The Department shall not impose requirements for prior
19approval based on a preferred drug list for anti-retroviral,
20anti-hemophilic factor concentrates, or any atypical
21antipsychotics, conventional antipsychotics, or
22anticonvulsants used for the treatment of serious mental
23illnesses until 30 days after it has conducted a study of the
24impact of such requirements on patient care and submitted a
25report to the Speaker of the House of Representatives and the
26President of the Senate. The Department shall review



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1utilization of narcotic medications in the medical assistance
2program and impose utilization controls that protect against
4    (e) When making determinations as to which drugs shall be
5on a prior approval list, the Department shall include as part
6of the analysis for this determination, the degree to which a
7drug may affect individuals in different ways based on factors
8including the gender of the person taking the medication.
9    (f) The Department shall cooperate with the Department of
10Public Health and the Department of Human Services Division of
11Mental Health in identifying psychotropic medications that,
12when given in a particular form, manner, duration, or frequency
13(including "as needed") in a dosage, or in conjunction with
14other psychotropic medications to a nursing home resident, may
15constitute a chemical restraint or an "unnecessary drug" as
16defined by the Nursing Home Care Act or Titles XVIII and XIX of
17the Social Security Act and the implementing rules and
18regulations. The Department shall require prior approval for
19any such medication prescribed for a nursing home resident that
20appears to be a chemical restraint or an unnecessary drug. The
21Department shall consult with the Department of Human Services
22Division of Mental Health in developing a protocol and criteria
23for deciding whether to grant such prior approval.
24    (g) The Department may by rule provide for reimbursement of
25the dispensing of a 90-day supply of a generic, non-narcotic
26maintenance medication in circumstances where it is cost



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2    (h) Effective July 1, 2011, the Department shall
3discontinue coverage of select over-the-counter drugs,
4including analgesics and cough and cold and allergy
6    (i) The Department shall seek any necessary waiver from the
7federal government in order to establish a program limiting the
8pharmacies eligible to dispense specialty drugs and shall issue
9a Request for Proposals in order to maximize savings on these
10drugs. The Department shall by rule establish the drugs
11required to be dispensed in this program.
12(Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10;
1396-1501, 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
17effect or shall cease to be imposed, and any moneys remaining
18in the Fund shall be refunded to hospital providers in
19proportion 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
4effect or shall cease to be imposed if the assessment is
5determined to be an impermissible tax under Title XIX of the
6Social Security Act. Moneys in the Hospital Provider Fund
7derived from assessments imposed prior thereto shall be
8disbursed in accordance with Section 5A-8 to the extent federal
9financial participation is not reduced due to the
10impermissibility of the assessments, and any remaining moneys
11shall be refunded to hospital providers in proportion to the
12amounts paid by them.
13(Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08; 96-8,
14eff. 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
18September 1, 1991, the Illinois Department shall reimburse
19hospitals for inpatient services at an inpatient payment rate
20calculated for each hospital based upon the Medicare
21Prospective Payment System as set forth in Sections 1886(b),
22(d), (g), and (h) of the federal Social Security Act, and the
23regulations, policies, and procedures promulgated thereunder,
24except as modified by this Section. Payment rates for inpatient
25hospital services rendered on or after September 1, 1991 and on



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1or before September 30, 1992 shall be calculated using the
2Medicare Prospective Payment rates in effect on September 1,
31991. Payment rates for inpatient hospital services rendered on
4or after October 1, 1992 and on or before March 31, 1994 shall
5be calculated using the Medicare Prospective Payment rates in
6effect on September 1, 1992. Payment rates for inpatient
7hospital services rendered on or after April 1, 1994 shall be
8calculated using the Medicare Prospective Payment rates
9(including the Medicare grouping methodology and weighting
10factors as adjusted pursuant to paragraph (1) of this
11subsection) in effect 90 days prior to the date of admission.
12For services rendered on or after July 1, 1995, the
13reimbursement methodology implemented under this subsection
14shall not include those costs referred to in Sections
151886(d)(5)(B) and 1886(h) of the Social Security Act. The
16additional payment amounts required under Section
171886(d)(5)(F) of the Social Security Act, for hospitals serving
18a disproportionate share of low-income or indigent patients,
19are not required under this Section. For hospital inpatient
20services rendered on or after July 1, 1995, the Illinois
21Department shall reimburse hospitals using the relative
22weighting factors and the base payment rates calculated for
23each hospital that were in effect on June 30, 1995, less the
24portion of such rates attributed by the Illinois Department to
25the 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
20of this Code, hospitals licensed under the University of
21Illinois Hospital Act, and facilities operated by the Illinois
22Department of Mental Health and Developmental Disabilities (or
23its successor, the Department of Human Services), for
24outpatient services rendered on or after July 1, 1995 and
25before July 1, 1998 the Illinois Department shall reimburse
26children's hospitals, as defined in the Illinois



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1Administrative Code Section 149.50(c)(3), at the rates in
2effect on June 30, 1995, less that portion of such rates
3attributed by the Illinois Department to the outpatient
4indigent volume adjustment and shall reimburse all other
5hospitals at the rates in effect on June 30, 1995, less the
6portions of such rates attributed by the Illinois Department to
7the cost of medical education and attributed by the Illinois
8Department to the outpatient indigent volume adjustment. For
9outpatient services provided on or after July 1, 1998,
10reimbursement rates shall be established by rule.
11    (c) In addition to any other payments under this Code, the
12Illinois Department shall develop a hospital disproportionate
13share reimbursement methodology that, effective July 1, 1991,
14through September 30, 1992, shall reimburse hospitals
15sufficiently to expend the fee monies described in subsection
16(b) of Section 14-3 of this Code and the federal matching funds
17received by the Illinois Department as a result of expenditures
18made by the Illinois Department as required by this subsection
19(c) and Section 14-2 that are attributable to fee monies
20deposited in the Fund, less amounts applied to adjustment
21payments 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
19inpatient services, effective with rate periods beginning on or
20after October 1, 1993, in addition to rates paid for inpatient
21services by the Illinois Department, the Illinois Department
22shall make adjustment payments for inpatient services
23furnished by Medicaid high volume hospitals. The Illinois
24Department shall establish by rule criteria for qualifying as a
25Medicaid high volume hospital and shall establish by rule a
26reimbursement methodology for calculating these adjustment



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1payments to Medicaid high volume hospitals. No adjustment
2payment shall be made under this subsection for services
3rendered on or after July 1, 1995.
4    (f) The Illinois Department shall modify its current rules
5governing adjustment payments for targeted access, critical
6care access, and uncompensated care to classify those
7adjustment payments as not being payments to disproportionate
8share hospitals under Title XIX of the federal Social Security
9Act. Rules adopted under this subsection shall not be effective
10with respect to services rendered on or after July 1, 1995. The
11Illinois Department has no obligation to adopt or implement any
12rules or make any payments under this subsection for services
13rendered on or after July 1, 1995.
14    (f-5) The State recognizes that adjustment payments to
15hospitals providing certain services or incurring certain
16costs may be necessary to assure that recipients of medical
17assistance have adequate access to necessary medical services.
18These adjustments include payments for teaching costs and
19uncompensated care, trauma center payments, rehabilitation
20hospital payments, perinatal center payments, obstetrical care
21payments, targeted access payments, Medicaid high volume
22payments, and outpatient indigent volume payments. On or before
23April 1, 1995, the Illinois Department shall issue
24recommendations regarding (i) reimbursement mechanisms or
25adjustment payments to reflect these costs and services,
26including methods by which the payments may be calculated and



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1the method by which the payments may be financed, and (ii)
2reimbursement mechanisms or adjustment payments to reflect
3costs and services of federally qualified health centers with
4respect to recipients of medical assistance.
5    (g) If one or more hospitals file suit in any court
6challenging any part of this Article XIV, payments to hospitals
7under this Article XIV shall be made only to the extent that
8sufficient monies are available in the Fund and only to the
9extent that any monies in the Fund are not prohibited from
10disbursement under any order of the court.
11    (h) Payments under the disbursement methodology described
12in this Section are subject to approval by the federal
13government in an appropriate State plan amendment.
14    (i) The Illinois Department may by rule establish criteria
15for and develop methodologies for adjustment payments to
16hospitals participating under this Article.
17    (j) Hospital Residing Long Term Care Services. In addition
18to any other payments made under this Code, the Illinois
19Department may by rule establish criteria and develop
20methodologies for payments to hospitals for Hospital Residing
21Long Term Care Services.
22    (k) Critical Access Hospital outpatient payments. In
23addition to any other payments authorized under this Code, the
24Illinois Department shall reimburse critical access hospitals,
25as designated by the Illinois Department of Public Health in
26accordance with 42 CFR 485, Subpart F, for outpatient services



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1at an amount that is no less than the cost of providing such
2services, based on Medicare cost principles. Payments under
3this 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
6Property Tax Relief and Pharmaceutical Assistance Act is
7amended 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
11individual who will become 65 years old during the calendar
12year in which a claim is filed, and any surviving spouse of
13such a claimant, who at the time of death received or was
14entitled to receive a grant pursuant to this Section, which
15surviving spouse will become 65 years of age within the 24
16months immediately following the death of such claimant and
17which surviving spouse but for his or her age is otherwise
18qualified to receive a grant pursuant to this Section, and any
19disabled person whose annual household income is less than the
20income eligibility limitation, as defined in subsection (a-5)
21and whose household is liable for payment of property taxes
22accrued or has paid rent constituting property taxes accrued
23and is domiciled in this State at the time he or she files his
24or her claim is entitled to claim a grant under this Act. With



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1respect to claims filed by individuals who will become 65 years
2old during the calendar year in which a claim is filed, the
3amount of any grant to which that household is entitled shall
4be an amount equal to 1/12 of the amount to which the claimant
5would otherwise be entitled as provided in this Section,
6multiplied by the number of months in which the claimant was 65
7in the calendar year in which the claim is filed.
8    (a-5) Income eligibility limitation. For purposes of this
9Section, "income eligibility limitation" means an amount for
10grant 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
18year 2010, a household must have annual household income of
19less than $27,610 for a household containing one person; less
20than $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
23January 1, 2011, and thereafter, the foregoing household income
24eligibility limits may be changed to reflect the annual cost of
25living adjustment in Social Security and Supplemental Security
26Income benefits that are applicable to the year for which those



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1benefits are being reported as income on an application.
2    If a person files as a surviving spouse, then only his or
3her income shall be counted in determining his or her household
5    (b) Limitation. Except as otherwise provided in
6subsections (a) and (f) of this Section, the maximum amount of
7grant which a claimant is entitled to claim is the amount by
8which the property taxes accrued which were paid or payable
9during the last preceding tax year or rent constituting
10property taxes accrued upon the claimant's residence for the
11last preceding taxable year exceeds 3 1/2% of the claimant's
12household income for that year but in no event is the grant to
13exceed (i) $700 less 4.5% of household income for that year for
14those with a household income of $14,000 or less or (ii) $70 if
15household income for that year is more than $14,000.
16    (c) Public aid recipients. If household income in one or
17more months during a year includes cash assistance in excess of
18$55 per month from the Department of Healthcare and Family
19Services or the Department of Human Services (acting as
20successor to the Department of Public Aid under the Department
21of Human Services Act) which was determined under regulations
22of that Department on a measure of need that included an
23allowance for actual rent or property taxes paid by the
24recipient of that assistance, the amount of grant to which that
25household is entitled, except as otherwise provided in
26subsection (a), shall be the product of (1) the maximum amount



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1computed as specified in subsection (b) of this Section and (2)
2the ratio of the number of months in which household income did
3not include such cash assistance over $55 to the number twelve.
4If household income did not include such cash assistance over
5$55 for any months during the year, the amount of the grant to
6which the household is entitled shall be the maximum amount
7computed as specified in subsection (b) of this Section. For
8purposes of this paragraph (c), "cash assistance" does not
9include any amount received under the federal Supplemental
10Security Income (SSI) program.
11    (d) Joint ownership. If title to the residence is held
12jointly by the claimant with a person who is not a member of
13his or her household, the amount of property taxes accrued used
14in computing the amount of grant to which he or she is entitled
15shall be the same percentage of property taxes accrued as is
16the percentage of ownership held by the claimant in the
18    (e) More than one residence. If a claimant has occupied
19more than one residence in the taxable year, he or she may
20claim only one residence for any part of a month. In the case
21of property taxes accrued, he or she shall prorate 1/12 of the
22total property taxes accrued on his or her residence to each
23month that he or she owned and occupied that residence; and, in
24the case of rent constituting property taxes accrued, shall
25prorate each month's rent payments to the residence actually
26occupied during that month.



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1    (f) (Blank).
2    (g) Effective January 1, 2006, there is hereby established
3a program of pharmaceutical assistance to the aged and
4disabled, entitled the Illinois Seniors and Disabled Drug
5Coverage Program, which shall be administered by the Department
6of Healthcare and Family Services and the Department on Aging
7in accordance with this subsection, to consist of coverage of
8specified prescription drugs on behalf of beneficiaries of the
9program as set forth in this subsection.
10    To become a beneficiary under the program established under
11this 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
11rules such that on January 1, 2011, and thereafter, the
12foregoing household income eligibility limits may be changed to
13reflect the annual cost of living adjustment in Social Security
14and Supplemental Security Income benefits that are applicable
15to the year for which those benefits are being reported as
16income on an application.
17    All individuals enrolled as of December 31, 2005, in the
18pharmaceutical assistance program operated pursuant to
19subsection (f) of this Section and all individuals enrolled as
20of December 31, 2005, in the SeniorCare Medicaid waiver program
21operated pursuant to Section 5-5.12a of the Illinois Public Aid
22Code shall be automatically enrolled in the program established
23by this subsection for the first year of operation without the
24need for further application, except that they must apply for
25Medicare Part D and the Low Income Subsidy under Medicare Part
26D. A person enrolled in the pharmaceutical assistance program



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1operated pursuant to subsection (f) of this Section as of
2December 31, 2005, shall not lose eligibility in future years
3due only to the fact that they have not reached the age of 65.
4    To the extent permitted by federal law, the Department may
5act as an authorized representative of a beneficiary in order
6to enroll the beneficiary in a Medicare Part D Prescription
7Drug Plan if the beneficiary has failed to choose a plan and,
8where possible, to enroll beneficiaries in the low-income
9subsidy program under Medicare Part D or assist them in
10enrolling in that program.
11    Beneficiaries under the program established under this
12subsection shall be divided into the following 4 eligibility
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
18contrary, the Department of Healthcare and Family Services may
19establish by emergency rule changes in cost-sharing necessary
20to conform the cost of the program to the amounts appropriated
21for State fiscal year 2012 and future fiscal years. The program
22established under this subsection shall cover the cost of
23covered prescription drugs in excess of the beneficiary
24cost-sharing amounts set forth in this paragraph that are not
25covered by Medicare. In 2006, beneficiaries shall pay a
26co-payment of $2 for each prescription of a generic drug and $5



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1for each prescription of a brand-name drug. In future years,
2beneficiaries shall pay co-payments equal to the co-payments
3required under Medicare Part D for "other low-income subsidy
4eligible individuals" pursuant to 42 CFR 423.782(b). For
5individuals in Eligibility Groups 1, 2, and 3, once the program
6established under this subsection and Medicare combined have
7paid $1,750 in a year for covered prescription drugs, the
8beneficiary shall pay 20% of the cost of each prescription in
9addition to the co-payments set forth in this paragraph. For
10individuals in Eligibility Group 4, once the program
11established under this subsection and Medicare combined have
12paid $1,750 in a year for covered prescription drugs, the
13beneficiary shall pay 20% of the cost of each prescription in
14addition to the co-payments set forth in this paragraph unless
15the drug is included in the formulary of the Illinois AIDS Drug
16Assistance Program operated by the Illinois Department of
17Public Health and covered by the Medicare Part D Prescription
18Drug Plan in which the beneficiary is enrolled. If the drug is
19included in the formulary of the Illinois AIDS Drug Assistance
20Program and covered by the Medicare Part D Prescription Drug
21Plan in which the beneficiary is enrolled, individuals in
22Eligibility Group 4 shall continue to pay the co-payments set
23forth in this paragraph after the program established under
24this subsection and Medicare combined have paid $1,750 in a
25year for covered prescription drugs.
26    For beneficiaries eligible for Medicare Part D coverage,



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1the program established under this subsection shall pay 100% of
2the premiums charged by a qualified Medicare Part D
3Prescription Drug Plan for Medicare Part D basic prescription
4drug coverage, not including any late enrollment penalties.
5Qualified Medicare Part D Prescription Drug Plans may be
6limited by the Department of Healthcare and Family Services to
7those plans that sign a coordination agreement with the
9    For Notwithstanding Section 3.15, for purposes of the
10program established under this subsection, the term "covered
11prescription 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
18receive a $25 monthly payment in lieu of the direct coverage
19described in this subsection.
20    Any person otherwise eligible for pharmaceutical
21assistance under this subsection whose covered drugs are
22covered by any public program is ineligible for assistance
23under this subsection to the extent that the cost of those
24drugs is covered by the other program.
25    The Department of Healthcare and Family Services shall
26establish by rule the methods by which it will provide for the



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1coverage called for in this subsection. Those methods may
2include direct reimbursement to pharmacies or the payment of a
3capitated amount to Medicare Part D Prescription Drug Plans.
4    For a pharmacy to be reimbursed under the program
5established under this subsection, it must comply with rules
6adopted by the Department of Healthcare and Family Services
7regarding coordination of benefits with Medicare Part D
8Prescription Drug Plans. A pharmacy may not charge a
9Medicare-enrolled beneficiary of the program established under
10this subsection more for a covered prescription drug than the
11appropriate Medicare cost-sharing less any payment from or on
12behalf of the Department of Healthcare and Family Services.
13    The Department of Healthcare and Family Services or the
14Department on Aging, as appropriate, may adopt rules regarding
15applications, counting of income, proof of Medicare status,
16mandatory generic policies, and pharmacy reimbursement rates
17and any other rules necessary for the cost-efficient operation
18of the program established under this subsection.
19    (h) A qualified individual is not entitled to duplicate
20benefits in a coverage period as a result of the changes made
21by this amendatory Act of the 96th General Assembly.
22(Source: P.A. 95-208, eff. 8-16-07; 95-644, eff. 10-12-07;
2395-876, eff. 8-21-08; 96-804, eff. 1-1-10; revised 9-16-10.)
24    Section 99. Effective date. This Act takes effect upon
25becoming law.".