Full Text of SB1784 97th General Assembly
SB1784enr 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 3. The Illinois Administrative Procedure Act is | 5 | | amended by changing Section 5-70 as follows:
| 6 | | (5 ILCS 100/5-70) (from Ch. 127, par. 1005-70)
| 7 | | Sec. 5-70. Form and publication of notices.
| 8 | | (a) The Secretary of State may prescribe reasonable rules | 9 | | concerning the
form of documents to be filed with the Secretary | 10 | | of State and may refuse to
accept for filing certified copies | 11 | | that do not comply with the rules. In
addition, the Secretary | 12 | | of State shall publish and maintain the Illinois
Register and | 13 | | may prescribe reasonable rules setting forth the manner in
| 14 | | which agencies shall submit notices required by this Act for | 15 | | publication in
the Illinois Register. The Illinois Register | 16 | | shall be published at least
once each week on the same day | 17 | | (unless that day is an official State
holiday, in which case | 18 | | the Illinois Register shall be published on the next
following | 19 | | business day) and sent to subscribers who subscribe for the
| 20 | | publication with the Secretary of State. The Secretary of State | 21 | | may charge
a subscription price to subscribers that covers | 22 | | mailing and publication costs.
| 23 | | (b) The Secretary of State shall accept for publication in |
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| 1 | | the Illinois
Register all Pollution Control Board documents, | 2 | | including but not limited
to Board opinions, the results of | 3 | | Board determinations concerning adjusted
standards | 4 | | proceedings, notices of petitions for individual adjusted
| 5 | | standards, results of Board determinations concerning the | 6 | | necessity for
economic impact studies, restricted status | 7 | | lists, hearing notices, and any
other documents related to the | 8 | | activities of the Pollution Control Board
that the Board deems | 9 | | appropriate for publication.
| 10 | | (c) The Secretary of State shall accept for publication in | 11 | | the Illinois Register notices initiated by the Department of | 12 | | Healthcare and Family Services in its capacity as the designate | 13 | | Title XIX single State agency pursuant to the requirements | 14 | | found at 42 CFR 447.205, and any other documents related to the | 15 | | activities of the programs administered by the Department of | 16 | | Healthcare and Family Services that the Department deems | 17 | | appropriate for publication. | 18 | | (Source: P.A. 87-823.)
| 19 | | (20 ILCS 10/Act rep.) | 20 | | Section 4. The Illinois Welfare and Rehabilitation | 21 | | Services Planning Act is repealed. | 22 | | Section 6. The State Finance Act is amended by changing | 23 | | Sections 5.573 and 6z-58 as follows:
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| 1 | | (30 ILCS 105/5.573)
| 2 | | Sec. 5.573. The Medical Interagency Program Family Care | 3 | | Fund. | 4 | | (Source: P.A. 95-331, eff. 8-21-07.)
| 5 | | (30 ILCS 105/6z-58)
| 6 | | Sec. 6z-58. The Medical Interagency Program Family Care | 7 | | Fund.
| 8 | | (a) There is created in the State treasury the Medical | 9 | | Interagency Program Family Care Fund. Interest
earned by the | 10 | | Fund shall be credited to the Fund.
| 11 | | (b) The Fund is created for the purposes of receiving, | 12 | | investing, and
distributing moneys in accordance with (i) an | 13 | | approved State plan or waiver under the Social
Security Act | 14 | | resulting from the Family Care waiver request submitted by the
| 15 | | Illinois Department of Public Aid on February 15, 2002 and (ii) | 16 | | an interagency agreement between the Department of Healthcare | 17 | | and Family Services (formerly Department of Public Aid) and | 18 | | another agency of State government. The Fund shall consist
of:
| 19 | | (1) All federal financial participation moneys | 20 | | received pursuant to expenditures from the Fund the
| 21 | | approved waiver, except for moneys received pursuant to | 22 | | expenditures for
medical services by the Department of | 23 | | Healthcare and Family Services (formerly
Department of | 24 | | Public Aid) from any other fund ; and
| 25 | | (2) All other moneys received by the Fund from any |
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| 1 | | source, including
interest thereon.
| 2 | | (c) Subject to appropriation, the moneys in the Fund shall | 3 | | be disbursed for
reimbursement of medical services and other | 4 | | costs associated with persons
receiving such services:
| 5 | | (1) under programs administered by the Department of | 6 | | Healthcare and Family Services (formerly Department of | 7 | | Public Aid); and | 8 | | (2) pursuant to an interagency agreement, under | 9 | | programs administered by another agency of State | 10 | | government.
| 11 | | (Source: P.A. 95-331, eff. 8-21-07.)
| 12 | | Section 10. The Nursing Home Care Act is amended by | 13 | | changing Section 2-201.5 as follows: | 14 | | (210 ILCS 45/2-201.5) | 15 | | Sec. 2-201.5. Screening prior to admission. | 16 | | (a) All persons age 18 or older seeking admission to a | 17 | | nursing
facility must be screened to
determine the need for | 18 | | nursing facility services prior to being admitted,
regardless | 19 | | of income, assets, or funding source. In addition, any person | 20 | | who
seeks to become eligible for medical assistance from the | 21 | | Medical Assistance
Program under the Illinois Public Aid Code | 22 | | to pay for long term care services
while residing in a facility | 23 | | must be screened prior to receiving those
benefits. Screening | 24 | | for nursing facility services shall be administered
through |
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| 1 | | procedures established by administrative rule. Screening may | 2 | | be done
by agencies other than the Department as established by | 3 | | administrative rule.
This Section applies on and after July 1, | 4 | | 1996. No later than October 1, 2010, the Department of | 5 | | Healthcare and Family Services, in collaboration with the | 6 | | Department on Aging, the Department of Human Services, and the | 7 | | Department of Public Health, shall file administrative rules | 8 | | providing for the gathering, during the screening process, of | 9 | | information relevant to determining each person's potential | 10 | | for placing other residents, employees, and visitors at risk of | 11 | | harm. | 12 | | (a-1) Any screening performed pursuant to subsection (a) of
| 13 | | this Section shall include a determination of whether any
| 14 | | person is being considered for admission to a nursing facility | 15 | | due to a
need for mental health services. For a person who | 16 | | needs
mental health services, the screening shall
also include | 17 | | an evaluation of whether there is permanent supportive housing, | 18 | | or an array of
community mental health services, including but | 19 | | not limited to
supported housing, assertive community | 20 | | treatment, and peer support services, that would enable the | 21 | | person to live in the community. The person shall be told about | 22 | | the existence of any such services that would enable the person | 23 | | to live safely and humanely and about available appropriate | 24 | | nursing home services that would enable the person to live | 25 | | safely and humanely, and the person shall be given the | 26 | | assistance necessary to avail himself or herself of any |
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| 1 | | available services. | 2 | | (a-2) Pre-screening for persons with a serious mental | 3 | | illness shall be performed by a psychiatrist, a psychologist, a | 4 | | registered nurse certified in psychiatric nursing, a licensed | 5 | | clinical professional counselor, or a licensed clinical social | 6 | | worker,
who is competent to (i) perform a clinical assessment | 7 | | of the individual, (ii) certify a diagnosis, (iii) make a
| 8 | | determination about the individual's current need for | 9 | | treatment, including substance abuse treatment, and recommend | 10 | | specific treatment, and (iv) determine whether a facility or a | 11 | | community-based program
is able to meet the needs of the | 12 | | individual. | 13 | | For any person entering a nursing facility, the | 14 | | pre-screening agent shall make specific recommendations about | 15 | | what care and services the individual needs to receive, | 16 | | beginning at admission, to attain or maintain the individual's | 17 | | highest level of independent functioning and to live in the | 18 | | most integrated setting appropriate for his or her physical and | 19 | | personal care and developmental and mental health needs. These | 20 | | recommendations shall be revised as appropriate by the | 21 | | pre-screening or re-screening agent based on the results of | 22 | | resident review and in response to changes in the resident's | 23 | | wishes, needs, and interest in transition. | 24 | | Upon the person entering the nursing facility, the | 25 | | Department of Human Services or its designee shall assist the | 26 | | person in establishing a relationship with a community mental |
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| 1 | | health agency or other appropriate agencies in order to (i) | 2 | | promote the person's transition to independent living and (ii) | 3 | | support the person's progress in meeting individual goals. | 4 | | (a-3) The Department of Human Services, by rule, shall | 5 | | provide for a prohibition on conflicts of interest for | 6 | | pre-admission screeners. The rule shall provide for waiver of | 7 | | those conflicts by the Department of Human Services if the | 8 | | Department of Human Services determines that a scarcity of | 9 | | qualified pre-admission screeners exists in a given community | 10 | | and that, absent a waiver of conflicts, an insufficient number | 11 | | of pre-admission screeners would be available. If a conflict is | 12 | | waived, the pre-admission screener shall disclose the conflict | 13 | | of interest to the screened individual in the manner provided | 14 | | for by rule of the Department of Human Services. For the | 15 | | purposes of this subsection, a "conflict of interest" includes, | 16 | | but is not limited to, the existence of a professional or | 17 | | financial relationship between (i) a PAS-MH corporate or a | 18 | | PAS-MH agent and (ii) a community provider or long-term care | 19 | | facility. | 20 | | (b) In addition to the screening required by subsection | 21 | | (a), a facility, except for those licensed as long term care | 22 | | for under age 22 facilities, shall, within 24 hours after | 23 | | admission, request a criminal history background check | 24 | | pursuant to the Uniform Conviction Information Act for all | 25 | | persons age 18 or older seeking admission to the facility, | 26 | | unless a background check was initiated by a hospital pursuant |
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| 1 | | to subsection (d) of Section 6.09 of the Hospital Licensing | 2 | | Act. Background checks conducted pursuant to this Section shall | 3 | | be based on the resident's name, date of birth, and other | 4 | | identifiers as required by the Department of State Police. If | 5 | | the results of the background check are inconclusive, the | 6 | | facility shall initiate a fingerprint-based check, unless the | 7 | | fingerprint check is waived by the Director of Public Health | 8 | | based on verification by the facility that the resident is | 9 | | completely immobile or that the resident meets other criteria | 10 | | related to the resident's health or lack of potential risk | 11 | | which may be established by Departmental rule. A waiver issued | 12 | | pursuant to this Section shall be valid only while the resident | 13 | | is immobile or while the criteria supporting the waiver exist. | 14 | | The facility shall provide for or arrange for any required | 15 | | fingerprint-based checks to be taken on the premises of the | 16 | | facility. If a fingerprint-based check is required, the | 17 | | facility shall arrange for it to be conducted in a manner that | 18 | | is respectful of the resident's dignity and that minimizes any | 19 | | emotional or physical hardship to the resident. | 20 | | (c) If the results of a resident's criminal history | 21 | | background check reveal that the resident is an identified | 22 | | offender as defined in Section 1-114.01, the facility shall do | 23 | | the following: | 24 | | (1) Immediately notify the Department of State Police, | 25 | | in the form and manner required by the Department of State | 26 | | Police, in collaboration with the Department of Public |
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| 1 | | Health, that the resident is an identified offender. | 2 | | (2) Within 72 hours, arrange for a fingerprint-based | 3 | | criminal history record inquiry to be requested on the | 4 | | identified offender resident. The inquiry shall be based on | 5 | | the subject's name, sex, race, date of birth, fingerprint | 6 | | images, and other identifiers required by the Department of | 7 | | State Police. The inquiry shall be processed through the | 8 | | files of the Department of State Police and the Federal | 9 | | Bureau of Investigation to locate any criminal history | 10 | | record information that may exist regarding the subject. | 11 | | The Federal Bureau of Investigation shall furnish to the | 12 | | Department of State Police,
pursuant to an inquiry under | 13 | | this paragraph (2),
any criminal history record | 14 | | information contained in its
files. | 15 | | The facility shall comply with all applicable provisions | 16 | | contained in the Uniform Conviction Information Act. | 17 | | All name-based and fingerprint-based criminal history | 18 | | record inquiries shall be submitted to the Department of State | 19 | | Police electronically in the form and manner prescribed by the | 20 | | Department of State Police. The Department of State Police may | 21 | | charge the facility a fee for processing name-based and | 22 | | fingerprint-based criminal history record inquiries. The fee | 23 | | shall be deposited into the State Police Services Fund. The fee | 24 | | shall not exceed the actual cost of processing the inquiry. | 25 | | (d) (Blank).
| 26 | | (e) The Department shall develop and maintain a |
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| 1 | | de-identified database of residents who have injured facility | 2 | | staff, facility visitors, or other residents, and the attendant | 3 | | circumstances, solely for the purposes of evaluating and | 4 | | improving resident pre-screening and assessment procedures | 5 | | (including the Criminal History Report prepared under Section | 6 | | 2-201.6) and the adequacy of Department requirements | 7 | | concerning the provision of care and services to residents. A | 8 | | resident shall not be listed in the database until a Department | 9 | | survey confirms the accuracy of the listing. The names of | 10 | | persons listed in the database and information that would allow | 11 | | them to be individually identified shall not be made public. | 12 | | Neither the Department nor any other agency of State government | 13 | | may use information in the database to take any action against | 14 | | any individual, licensee, or other entity, unless the | 15 | | Department or agency receives the information independent of | 16 | | this subsection (e). All information
collected, maintained, or | 17 | | developed under the authority of this subsection (e) for the | 18 | | purposes of the database maintained under this subsection (e) | 19 | | shall be treated in the same manner as information that is | 20 | | subject to Part 21 of Article VIII of the Code of Civil | 21 | | Procedure. | 22 | | (Source: P.A. 96-1372, eff. 7-29-10.) | 23 | | Section 15. The Illinois Public Aid Code is amended by | 24 | | changing Sections 5-2, 5-5, 5-26, 5A-9, 12-4.42, and 12-10.5 as | 25 | | follows:
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| 1 | | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| 2 | | Sec. 5-2. Classes of Persons Eligible. Medical assistance | 3 | | under this
Article shall be available to any of the following | 4 | | classes of persons in
respect to whom a plan for coverage has | 5 | | been submitted to the Governor
by the Illinois Department and | 6 | | approved by him:
| 7 | | 1. Recipients of basic maintenance grants under | 8 | | Articles III and IV.
| 9 | | 2. Persons otherwise eligible for basic maintenance | 10 | | under Articles
III and IV, excluding any eligibility | 11 | | requirements that are inconsistent with any federal law or | 12 | | federal regulation, as interpreted by the U.S. Department | 13 | | of Health and Human Services, but who fail to qualify | 14 | | thereunder on the basis of need or who qualify but are not | 15 | | receiving basic maintenance under Article IV, and
who have | 16 | | insufficient income and resources to meet the costs of
| 17 | | necessary medical care, including but not limited to the | 18 | | following:
| 19 | | (a) All persons otherwise eligible for basic | 20 | | maintenance under Article
III but who fail to qualify | 21 | | under that Article on the basis of need and who
meet | 22 | | either of the following requirements:
| 23 | | (i) their income, as determined by the | 24 | | Illinois Department in
accordance with any federal | 25 | | requirements, is equal to or less than 70% in
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| 1 | | fiscal year 2001, equal to or less than 85% in | 2 | | fiscal year 2002 and until
a date to be determined | 3 | | by the Department by rule, and equal to or less
| 4 | | than 100% beginning on the date determined by the | 5 | | Department by rule, of the nonfarm income official | 6 | | poverty
line, as defined by the federal Office of | 7 | | Management and Budget and revised
annually in | 8 | | accordance with Section 673(2) of the Omnibus | 9 | | Budget Reconciliation
Act of 1981, applicable to | 10 | | families of the same size; or
| 11 | | (ii) their income, after the deduction of | 12 | | costs incurred for medical
care and for other types | 13 | | of remedial care, is equal to or less than 70% in
| 14 | | fiscal year 2001, equal to or less than 85% in | 15 | | fiscal year 2002 and until
a date to be determined | 16 | | by the Department by rule, and equal to or less
| 17 | | than 100% beginning on the date determined by the | 18 | | Department by rule, of the nonfarm income official | 19 | | poverty
line, as defined in item (i) of this | 20 | | subparagraph (a).
| 21 | | (b) All persons who, excluding any eligibility | 22 | | requirements that are inconsistent with any federal | 23 | | law or federal regulation, as interpreted by the U.S. | 24 | | Department of Health and Human Services, would be | 25 | | determined eligible for such basic
maintenance under | 26 | | Article IV by disregarding the maximum earned income
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| 1 | | permitted by federal law.
| 2 | | 3. Persons who would otherwise qualify for Aid to the | 3 | | Medically
Indigent under Article VII.
| 4 | | 4. Persons not eligible under any of the preceding | 5 | | paragraphs who fall
sick, are injured, or die, not having | 6 | | sufficient money, property or other
resources to meet the | 7 | | costs of necessary medical care or funeral and burial
| 8 | | expenses.
| 9 | | 5.(a) Women during pregnancy, after the fact
of | 10 | | pregnancy has been determined by medical diagnosis, and | 11 | | during the
60-day period beginning on the last day of the | 12 | | pregnancy, together with
their infants and children born | 13 | | after September 30, 1983,
whose income and
resources are | 14 | | insufficient to meet the costs of necessary medical care to
| 15 | | the maximum extent possible under Title XIX of the
Federal | 16 | | Social Security Act.
| 17 | | (b) The Illinois Department and the Governor shall | 18 | | provide a plan for
coverage of the persons eligible under | 19 | | paragraph 5(a) by April 1, 1990. Such
plan shall provide | 20 | | ambulatory prenatal care to pregnant women during a
| 21 | | presumptive eligibility period and establish an income | 22 | | eligibility standard
that is equal to 133%
of the nonfarm | 23 | | income official poverty line, as defined by
the federal | 24 | | Office of Management and Budget and revised annually in
| 25 | | accordance with Section 673(2) of the Omnibus Budget | 26 | | Reconciliation Act of
1981, applicable to families of the |
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| 1 | | same size, provided that costs incurred
for medical care | 2 | | are not taken into account in determining such income
| 3 | | eligibility.
| 4 | | (c) The Illinois Department may conduct a | 5 | | demonstration in at least one
county that will provide | 6 | | medical assistance to pregnant women, together
with their | 7 | | infants and children up to one year of age,
where the | 8 | | income
eligibility standard is set up to 185% of the | 9 | | nonfarm income official
poverty line, as defined by the | 10 | | federal Office of Management and Budget.
The Illinois | 11 | | Department shall seek and obtain necessary authorization
| 12 | | provided under federal law to implement such a | 13 | | demonstration. Such
demonstration may establish resource | 14 | | standards that are not more
restrictive than those | 15 | | established under Article IV of this Code.
| 16 | | 6. Persons under the age of 18 who fail to qualify as | 17 | | dependent under
Article IV and who have insufficient income | 18 | | and resources to meet the costs
of necessary medical care | 19 | | to the maximum extent permitted under Title XIX
of the | 20 | | Federal Social Security Act.
| 21 | | 7. Persons who are under 21 years of age and would
| 22 | | qualify as
disabled as defined under the Federal | 23 | | Supplemental Security Income Program,
provided medical | 24 | | service for such persons would be eligible for Federal
| 25 | | Financial Participation, and provided the Illinois | 26 | | Department determines that:
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| 1 | | (a) the person requires a level of care provided by | 2 | | a hospital, skilled
nursing facility, or intermediate | 3 | | care facility, as determined by a physician
licensed to | 4 | | practice medicine in all its branches;
| 5 | | (b) it is appropriate to provide such care outside | 6 | | of an institution, as
determined by a physician | 7 | | licensed to practice medicine in all its branches;
| 8 | | (c) the estimated amount which would be expended | 9 | | for care outside the
institution is not greater than | 10 | | the estimated amount which would be
expended in an | 11 | | institution.
| 12 | | 8. Persons who become ineligible for basic maintenance | 13 | | assistance
under Article IV of this Code in programs | 14 | | administered by the Illinois
Department due to employment | 15 | | earnings and persons in
assistance units comprised of | 16 | | adults and children who become ineligible for
basic | 17 | | maintenance assistance under Article VI of this Code due to
| 18 | | employment earnings. The plan for coverage for this class | 19 | | of persons shall:
| 20 | | (a) extend the medical assistance coverage for up | 21 | | to 12 months following
termination of basic | 22 | | maintenance assistance; and
| 23 | | (b) offer persons who have initially received 6 | 24 | | months of the
coverage provided in paragraph (a) above, | 25 | | the option of receiving an
additional 6 months of | 26 | | coverage, subject to the following:
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| 1 | | (i) such coverage shall be pursuant to | 2 | | provisions of the federal
Social Security Act;
| 3 | | (ii) such coverage shall include all services | 4 | | covered while the person
was eligible for basic | 5 | | maintenance assistance;
| 6 | | (iii) no premium shall be charged for such | 7 | | coverage; and
| 8 | | (iv) such coverage shall be suspended in the | 9 | | event of a person's
failure without good cause to | 10 | | file in a timely fashion reports required for
this | 11 | | coverage under the Social Security Act and | 12 | | coverage shall be reinstated
upon the filing of | 13 | | such reports if the person remains otherwise | 14 | | eligible.
| 15 | | 9. Persons with acquired immunodeficiency syndrome | 16 | | (AIDS) or with
AIDS-related conditions with respect to whom | 17 | | there has been a determination
that but for home or | 18 | | community-based services such individuals would
require | 19 | | the level of care provided in an inpatient hospital, | 20 | | skilled
nursing facility or intermediate care facility the | 21 | | cost of which is
reimbursed under this Article. Assistance | 22 | | shall be provided to such
persons to the maximum extent | 23 | | permitted under Title
XIX of the Federal Social Security | 24 | | Act.
| 25 | | 10. Participants in the long-term care insurance | 26 | | partnership program
established under the Illinois |
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| 1 | | Long-Term Care Partnership Program Act who meet the
| 2 | | qualifications for protection of resources described in | 3 | | Section 15 of that
Act.
| 4 | | 11. Persons with disabilities who are employed and | 5 | | eligible for Medicaid,
pursuant to Section | 6 | | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, | 7 | | subject to federal approval, persons with a medically | 8 | | improved disability who are employed and eligible for | 9 | | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | 10 | | the Social Security Act, as
provided by the Illinois | 11 | | Department by rule. In establishing eligibility standards | 12 | | under this paragraph 11, the Department shall, subject to | 13 | | federal approval: | 14 | | (a) set the income eligibility standard at not | 15 | | lower than 350% of the federal poverty level; | 16 | | (b) exempt retirement accounts that the person | 17 | | cannot access without penalty before the age
of 59 1/2, | 18 | | and medical savings accounts established pursuant to | 19 | | 26 U.S.C. 220; | 20 | | (c) allow non-exempt assets up to $25,000 as to | 21 | | those assets accumulated during periods of eligibility | 22 | | under this paragraph 11; and
| 23 | | (d) continue to apply subparagraphs (b) and (c) in | 24 | | determining the eligibility of the person under this | 25 | | Article even if the person loses eligibility under this | 26 | | paragraph 11.
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| 1 | | 12. Subject to federal approval, persons who are | 2 | | eligible for medical
assistance coverage under applicable | 3 | | provisions of the federal Social Security
Act and the | 4 | | federal Breast and Cervical Cancer Prevention and | 5 | | Treatment Act of
2000. Those eligible persons are defined | 6 | | to include, but not be limited to,
the following persons:
| 7 | | (1) persons who have been screened for breast or | 8 | | cervical cancer under
the U.S. Centers for Disease | 9 | | Control and Prevention Breast and Cervical Cancer
| 10 | | Program established under Title XV of the federal | 11 | | Public Health Services Act in
accordance with the | 12 | | requirements of Section 1504 of that Act as | 13 | | administered by
the Illinois Department of Public | 14 | | Health; and
| 15 | | (2) persons whose screenings under the above | 16 | | program were funded in whole
or in part by funds | 17 | | appropriated to the Illinois Department of Public | 18 | | Health
for breast or cervical cancer screening.
| 19 | | "Medical assistance" under this paragraph 12 shall be | 20 | | identical to the benefits
provided under the State's | 21 | | approved plan under Title XIX of the Social Security
Act. | 22 | | The Department must request federal approval of the | 23 | | coverage under this
paragraph 12 within 30 days after the | 24 | | effective date of this amendatory Act of
the 92nd General | 25 | | Assembly.
| 26 | | In addition to the persons who are eligible for medical |
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| 1 | | assistance pursuant to subparagraphs (1) and (2) of this | 2 | | paragraph 12, and to be paid from funds appropriated to the | 3 | | Department for its medical programs, any uninsured person | 4 | | as defined by the Department in rules residing in Illinois | 5 | | who is younger than 65 years of age, who has been screened | 6 | | for breast and cervical cancer in accordance with standards | 7 | | and procedures adopted by the Department of Public Health | 8 | | for screening, and who is referred to the Department by the | 9 | | Department of Public Health as being in need of treatment | 10 | | for breast or cervical cancer is eligible for medical | 11 | | assistance benefits that are consistent with the benefits | 12 | | provided to those persons described in subparagraphs (1) | 13 | | and (2). Medical assistance coverage for the persons who | 14 | | are eligible under the preceding sentence is not dependent | 15 | | on federal approval, but federal moneys may be used to pay | 16 | | for services provided under that coverage upon federal | 17 | | approval. | 18 | | 13. Subject to appropriation and to federal approval, | 19 | | persons living with HIV/AIDS who are not otherwise eligible | 20 | | under this Article and who qualify for services covered | 21 | | under Section 5-5.04 as provided by the Illinois Department | 22 | | by rule.
| 23 | | 14. Subject to the availability of funds for this | 24 | | purpose, the Department may provide coverage under this | 25 | | Article to persons who reside in Illinois who are not | 26 | | eligible under any of the preceding paragraphs and who meet |
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| 1 | | the income guidelines of paragraph 2(a) of this Section and | 2 | | (i) have an application for asylum pending before the | 3 | | federal Department of Homeland Security or on appeal before | 4 | | a court of competent jurisdiction and are represented | 5 | | either by counsel or by an advocate accredited by the | 6 | | federal Department of Homeland Security and employed by a | 7 | | not-for-profit organization in regard to that application | 8 | | or appeal, or (ii) are receiving services through a | 9 | | federally funded torture treatment center. Medical | 10 | | coverage under this paragraph 14 may be provided for up to | 11 | | 24 continuous months from the initial eligibility date so | 12 | | long as an individual continues to satisfy the criteria of | 13 | | this paragraph 14. If an individual has an appeal pending | 14 | | regarding an application for asylum before the Department | 15 | | of Homeland Security, eligibility under this paragraph 14 | 16 | | may be extended until a final decision is rendered on the | 17 | | appeal. The Department may adopt rules governing the | 18 | | implementation of this paragraph 14.
| 19 | | 15. Family Care Eligibility. | 20 | | (a) A caretaker relative who is 19 years of age or | 21 | | older when countable income is at or below 185% of the | 22 | | Federal Poverty Level Guidelines, as published | 23 | | annually in the Federal Register, for the appropriate | 24 | | family size. A person may not spend down to become | 25 | | 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 | | 60 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 5/5-5) (from Ch. 23, par. 5-5)
| 22 | | Sec. 5-5. Medical services. The Illinois Department, by | 23 | | rule, shall
determine the quantity and quality of and the rate | 24 | | of reimbursement for the
medical assistance for which
payment | 25 | | will be authorized, and the medical services to be provided,
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| 1 | | which may include all or part of the following: (1) inpatient | 2 | | hospital
services; (2) outpatient hospital services; (3) other | 3 | | laboratory and
X-ray services; (4) skilled nursing home | 4 | | services; (5) physicians'
services whether furnished in the | 5 | | office, the patient's home, a
hospital, a skilled nursing home, | 6 | | or elsewhere; (6) medical care, or any
other type of remedial | 7 | | care furnished by licensed practitioners; (7)
home health care | 8 | | services; (8) private duty nursing service; (9) clinic
| 9 | | services; (10) dental services, including prevention and | 10 | | treatment of periodontal disease and dental caries disease for | 11 | | pregnant women, provided by an individual licensed to practice | 12 | | dentistry or dental surgery; for purposes of this item (10), | 13 | | "dental services" means diagnostic, preventive, or corrective | 14 | | procedures provided by or under the supervision of a dentist in | 15 | | the practice of his or her profession; (11) physical therapy | 16 | | and related
services; (12) prescribed drugs, dentures, and | 17 | | prosthetic devices; and
eyeglasses prescribed by a physician | 18 | | skilled in the diseases of the eye,
or by an optometrist, | 19 | | whichever the person may select; (13) other
diagnostic, | 20 | | screening, preventive, and rehabilitative services , for | 21 | | children and adults ; (14)
transportation and such other | 22 | | expenses as may be necessary; (15) medical
treatment of sexual | 23 | | assault survivors, as defined in
Section 1a of the Sexual | 24 | | Assault Survivors Emergency Treatment Act, for
injuries | 25 | | sustained as a result of the sexual assault, including
| 26 | | examinations and laboratory tests to discover evidence which |
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| 1 | | may be used in
criminal proceedings arising from the sexual | 2 | | assault; (16) the
diagnosis and treatment of sickle cell | 3 | | anemia; and (17)
any other medical care, and any other type of | 4 | | remedial care recognized
under the laws of this State, but not | 5 | | including abortions, or induced
miscarriages or premature | 6 | | births, unless, in the opinion of a physician,
such procedures | 7 | | are necessary for the preservation of the life of the
woman | 8 | | seeking such treatment, or except an induced premature birth
| 9 | | intended to produce a live viable child and such procedure is | 10 | | necessary
for the health of the mother or her unborn child. The | 11 | | Illinois Department,
by rule, shall prohibit any physician from | 12 | | providing medical assistance
to anyone eligible therefor under | 13 | | this Code where such physician has been
found guilty of | 14 | | performing an abortion procedure in a wilful and wanton
manner | 15 | | upon a woman who was not pregnant at the time such abortion
| 16 | | procedure was performed. The term "any other type of remedial | 17 | | care" shall
include nursing care and nursing home service for | 18 | | persons who rely on
treatment by spiritual means alone through | 19 | | prayer for healing.
| 20 | | Notwithstanding any other provision of this Section, a | 21 | | comprehensive
tobacco use cessation program that includes | 22 | | purchasing prescription drugs or
prescription medical devices | 23 | | approved by the Food and Drug Administration shall
be covered | 24 | | under the medical assistance
program under this Article for | 25 | | persons who are otherwise eligible for
assistance under this | 26 | | Article.
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| 1 | | Notwithstanding any other provision of this Code, the | 2 | | Illinois
Department may not require, as a condition of payment | 3 | | for any laboratory
test authorized under this Article, that a | 4 | | physician's handwritten signature
appear on the laboratory | 5 | | test order form. The Illinois Department may,
however, impose | 6 | | other appropriate requirements regarding laboratory test
order | 7 | | documentation.
| 8 | | The Department of Healthcare and Family Services shall | 9 | | provide the following services to
persons
eligible for | 10 | | assistance under this Article who are participating in
| 11 | | education, training or employment programs operated by the | 12 | | Department of Human
Services as successor to the Department of | 13 | | Public Aid:
| 14 | | (1) dental services provided by or under the | 15 | | supervision of a dentist; and
| 16 | | (2) eyeglasses prescribed by a physician skilled in the | 17 | | diseases of the
eye, or by an optometrist, whichever the | 18 | | person may select.
| 19 | | Notwithstanding any other provision of this Code and | 20 | | subject to federal approval, the Department may adopt rules to | 21 | | allow a dentist who is volunteering his or her service at no | 22 | | cost to render dental services through an enrolled | 23 | | not-for-profit health clinic without the dentist personally | 24 | | enrolling as a participating provider in the medical assistance | 25 | | program. A not-for-profit health clinic shall include a public | 26 | | health clinic or Federally Qualified Health Center or other |
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| 1 | | enrolled provider, as determined by the Department, through | 2 | | which dental services covered under this Section are performed. | 3 | | The Department shall establish a process for payment of claims | 4 | | for reimbursement for covered dental services rendered under | 5 | | this provision. | 6 | | The Illinois Department, by rule, may distinguish and | 7 | | classify the
medical services to be provided only in accordance | 8 | | with the classes of
persons designated in Section 5-2.
| 9 | | The Department of Healthcare and Family Services must | 10 | | provide coverage and reimbursement for amino acid-based | 11 | | elemental formulas, regardless of delivery method, for the | 12 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 13 | | short bowel syndrome when the prescribing physician has issued | 14 | | a written order stating that the amino acid-based elemental | 15 | | formula is medically necessary.
| 16 | | The Illinois Department shall authorize the provision of, | 17 | | and shall
authorize payment for, screening by low-dose | 18 | | mammography for the presence of
occult breast cancer for women | 19 | | 35 years of age or older who are eligible
for medical | 20 | | assistance under this Article, as follows: | 21 | | (A) A baseline
mammogram for women 35 to 39 years of | 22 | | age.
| 23 | | (B) An annual mammogram for women 40 years of age or | 24 | | older. | 25 | | (C) A mammogram at the age and intervals considered | 26 | | medically necessary by the woman's health care provider for |
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| 1 | | women under 40 years of age and having a family history of | 2 | | breast cancer, prior personal history of breast cancer, | 3 | | positive genetic testing, or other risk factors. | 4 | | (D) A comprehensive ultrasound screening of an entire | 5 | | breast or breasts if a mammogram demonstrates | 6 | | heterogeneous or dense breast tissue, when medically | 7 | | necessary as determined by a physician licensed to practice | 8 | | medicine in all of its branches. | 9 | | All screenings
shall
include a physical breast exam, | 10 | | instruction on self-examination and
information regarding the | 11 | | frequency of self-examination and its value as a
preventative | 12 | | tool. For purposes of this Section, "low-dose mammography" | 13 | | means
the x-ray examination of the breast using equipment | 14 | | dedicated specifically
for mammography, including the x-ray | 15 | | tube, filter, compression device,
and image receptor, with an | 16 | | average radiation exposure delivery
of less than one rad per | 17 | | breast for 2 views of an average size breast.
The term also | 18 | | includes digital mammography.
| 19 | | On and after July 1, 2008, screening and diagnostic | 20 | | mammography shall be reimbursed at the same rate as the | 21 | | Medicare program's rates, including the increased | 22 | | reimbursement for digital mammography. | 23 | | The Department shall convene an expert panel including | 24 | | representatives of hospitals, free-standing mammography | 25 | | facilities, and doctors, including radiologists, to establish | 26 | | quality standards. Based on these quality standards, the |
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| 1 | | Department shall provide for bonus payments to mammography | 2 | | facilities meeting the standards for screening and diagnosis. | 3 | | The bonus payments shall be at least 15% higher than the | 4 | | Medicare rates for mammography. | 5 | | Subject to federal approval, the Department shall | 6 | | establish a rate methodology for mammography at federally | 7 | | qualified health centers and other encounter-rate clinics. | 8 | | These clinics or centers may also collaborate with other | 9 | | hospital-based mammography facilities. | 10 | | The Department shall establish a methodology to remind | 11 | | women who are age-appropriate for screening mammography, but | 12 | | who have not received a mammogram within the previous 18 | 13 | | months, of the importance and benefit of screening mammography. | 14 | | The Department shall establish a performance goal for | 15 | | primary care providers with respect to their female patients | 16 | | over age 40 receiving an annual mammogram. This performance | 17 | | goal shall be used to provide additional reimbursement in the | 18 | | form of a quality performance bonus to primary care providers | 19 | | who meet that goal. | 20 | | The Department shall devise a means of case-managing or | 21 | | patient navigation for beneficiaries diagnosed with breast | 22 | | cancer. This program shall initially operate as a pilot program | 23 | | in areas of the State with the highest incidence of mortality | 24 | | related to breast cancer. At least one pilot program site shall | 25 | | be in the metropolitan Chicago area and at least one site shall | 26 | | be outside the metropolitan Chicago area. An evaluation of the |
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| 1 | | pilot program shall be carried out measuring health outcomes | 2 | | and cost of care for those served by the pilot program compared | 3 | | to similarly situated patients who are not served by the pilot | 4 | | program. | 5 | | Any medical or health care provider shall immediately | 6 | | recommend, to
any pregnant woman who is being provided prenatal | 7 | | services and is suspected
of drug abuse or is addicted as | 8 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 9 | | Act, referral to a local substance abuse treatment provider
| 10 | | licensed by the Department of Human Services or to a licensed
| 11 | | hospital which provides substance abuse treatment services. | 12 | | The Department of Healthcare and Family Services
shall assure | 13 | | coverage for the cost of treatment of the drug abuse or
| 14 | | addiction for pregnant recipients in accordance with the | 15 | | Illinois Medicaid
Program in conjunction with the Department of | 16 | | Human Services.
| 17 | | All medical providers providing medical assistance to | 18 | | pregnant women
under this Code shall receive information from | 19 | | the Department on the
availability of services under the Drug | 20 | | Free Families with a Future or any
comparable program providing | 21 | | case management services for addicted women,
including | 22 | | information on appropriate referrals for other social services
| 23 | | that may be needed by addicted women in addition to treatment | 24 | | for addiction.
| 25 | | The Illinois Department, in cooperation with the | 26 | | Departments of Human
Services (as successor to the Department |
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| 1 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 2 | | public awareness campaign, may
provide information concerning | 3 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 4 | | health care, and other pertinent programs directed at
reducing | 5 | | the number of drug-affected infants born to recipients of | 6 | | medical
assistance.
| 7 | | Neither the Department of Healthcare and Family Services | 8 | | nor the Department of Human
Services shall sanction the | 9 | | recipient solely on the basis of
her substance abuse.
| 10 | | The Illinois Department shall establish such regulations | 11 | | governing
the dispensing of health services under this Article | 12 | | as it shall deem
appropriate. The Department
should
seek the | 13 | | advice of formal professional advisory committees appointed by
| 14 | | the Director of the Illinois Department for the purpose of | 15 | | providing regular
advice on policy and administrative matters, | 16 | | information dissemination and
educational activities for | 17 | | medical and health care providers, and
consistency in | 18 | | procedures to the Illinois Department.
| 19 | | Notwithstanding any other provision of law, a health care | 20 | | provider under the medical assistance program may elect, in | 21 | | lieu of receiving direct payment for services provided under | 22 | | that program, to participate in the State Employees Deferred | 23 | | Compensation Plan adopted under Article 24 of the Illinois | 24 | | Pension Code. A health care provider who elects to participate | 25 | | in the plan does not have a cause of action against the State | 26 | | for any damages allegedly suffered by the provider as a result |
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| 1 | | of any delay by the State in crediting the amount of any | 2 | | contribution to the provider's plan account. | 3 | | The Illinois Department may develop and contract with | 4 | | Partnerships of
medical providers to arrange medical services | 5 | | for persons eligible under
Section 5-2 of this Code. | 6 | | Implementation of this Section may be by
demonstration projects | 7 | | in certain geographic areas. The Partnership shall
be | 8 | | represented by a sponsor organization. The Department, by rule, | 9 | | shall
develop qualifications for sponsors of Partnerships. | 10 | | Nothing in this
Section shall be construed to require that the | 11 | | sponsor organization be a
medical organization.
| 12 | | The sponsor must negotiate formal written contracts with | 13 | | medical
providers for physician services, inpatient and | 14 | | outpatient hospital care,
home health services, treatment for | 15 | | alcoholism and substance abuse, and
other services determined | 16 | | necessary by the Illinois Department by rule for
delivery by | 17 | | Partnerships. Physician services must include prenatal and
| 18 | | obstetrical care. The Illinois Department shall reimburse | 19 | | medical services
delivered by Partnership providers to clients | 20 | | in target areas according to
provisions of this Article and the | 21 | | Illinois Health Finance Reform Act,
except that:
| 22 | | (1) Physicians participating in a Partnership and | 23 | | providing certain
services, which shall be determined by | 24 | | the Illinois Department, to persons
in areas covered by the | 25 | | Partnership may receive an additional surcharge
for such | 26 | | services.
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| 1 | | (2) The Department may elect to consider and negotiate | 2 | | financial
incentives to encourage the development of | 3 | | Partnerships and the efficient
delivery of medical care.
| 4 | | (3) Persons receiving medical services through | 5 | | Partnerships may receive
medical and case management | 6 | | services above the level usually offered
through the | 7 | | medical assistance program.
| 8 | | Medical providers shall be required to meet certain | 9 | | qualifications to
participate in Partnerships to ensure the | 10 | | delivery of high quality medical
services. These | 11 | | qualifications shall be determined by rule of the Illinois
| 12 | | Department and may be higher than qualifications for | 13 | | participation in the
medical assistance program. Partnership | 14 | | sponsors may prescribe reasonable
additional qualifications | 15 | | for participation by medical providers, only with
the prior | 16 | | written approval of the Illinois Department.
| 17 | | Nothing in this Section shall limit the free choice of | 18 | | practitioners,
hospitals, and other providers of medical | 19 | | services by clients.
In order to ensure patient freedom of | 20 | | choice, the Illinois Department shall
immediately promulgate | 21 | | all rules and take all other necessary actions so that
provided | 22 | | services may be accessed from therapeutically certified | 23 | | optometrists
to the full extent of the Illinois Optometric | 24 | | Practice Act of 1987 without
discriminating between service | 25 | | providers.
| 26 | | The Department shall apply for a waiver from the United |
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| 1 | | States Health
Care Financing Administration to allow for the | 2 | | implementation of
Partnerships under this Section.
| 3 | | The Illinois Department shall require health care | 4 | | providers to maintain
records that document the medical care | 5 | | and services provided to recipients
of Medical Assistance under | 6 | | this Article. Such records must be retained for a period of not | 7 | | less than 6 years from the date of service or as provided by | 8 | | applicable State law, whichever period is longer, except that | 9 | | if an audit is initiated within the required retention period | 10 | | then the records must be retained until the audit is completed | 11 | | and every exception is resolved. The Illinois Department shall
| 12 | | require health care providers to make available, when | 13 | | authorized by the
patient, in writing, the medical records in a | 14 | | timely fashion to other
health care providers who are treating | 15 | | or serving persons eligible for
Medical Assistance under this | 16 | | Article. All dispensers of medical services
shall be required | 17 | | to maintain and retain business and professional records
| 18 | | sufficient to fully and accurately document the nature, scope, | 19 | | details and
receipt of the health care provided to persons | 20 | | eligible for medical
assistance under this Code, in accordance | 21 | | with regulations promulgated by
the Illinois Department. The | 22 | | rules and regulations shall require that proof
of the receipt | 23 | | of prescription drugs, dentures, prosthetic devices and
| 24 | | eyeglasses by eligible persons under this Section accompany | 25 | | each claim
for reimbursement submitted by the dispenser of such | 26 | | medical services.
No such claims for reimbursement shall be |
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| 1 | | approved for payment by the Illinois
Department without such | 2 | | proof of receipt, unless the Illinois Department
shall have put | 3 | | into effect and shall be operating a system of post-payment
| 4 | | audit and review which shall, on a sampling basis, be deemed | 5 | | adequate by
the Illinois Department to assure that such drugs, | 6 | | dentures, prosthetic
devices and eyeglasses for which payment | 7 | | is being made are actually being
received by eligible | 8 | | recipients. Within 90 days after the effective date of
this | 9 | | amendatory Act of 1984, the Illinois Department shall establish | 10 | | a
current list of acquisition costs for all prosthetic devices | 11 | | and any
other items recognized as medical equipment and | 12 | | supplies reimbursable under
this Article and shall update such | 13 | | list on a quarterly basis, except that
the acquisition costs of | 14 | | all prescription drugs shall be updated no
less frequently than | 15 | | every 30 days as required by Section 5-5.12.
| 16 | | The rules and regulations of the Illinois Department shall | 17 | | require
that a written statement including the required opinion | 18 | | of a physician
shall accompany any claim for reimbursement for | 19 | | abortions, or induced
miscarriages or premature births. This | 20 | | statement shall indicate what
procedures were used in providing | 21 | | such medical services.
| 22 | | The Illinois Department shall require all dispensers of | 23 | | medical
services, other than an individual practitioner or | 24 | | group of practitioners,
desiring to participate in the Medical | 25 | | Assistance program
established under this Article to disclose | 26 | | all financial, beneficial,
ownership, equity, surety or other |
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| 1 | | interests in any and all firms,
corporations, partnerships, | 2 | | associations, business enterprises, joint
ventures, agencies, | 3 | | institutions or other legal entities providing any
form of | 4 | | health care services in this State under this Article.
| 5 | | The Illinois Department may require that all dispensers of | 6 | | medical
services desiring to participate in the medical | 7 | | assistance program
established under this Article disclose, | 8 | | under such terms and conditions as
the Illinois Department may | 9 | | by rule establish, all inquiries from clients
and attorneys | 10 | | regarding medical bills paid by the Illinois Department, which
| 11 | | inquiries could indicate potential existence of claims or liens | 12 | | for the
Illinois Department.
| 13 | | Enrollment of a vendor that provides non-emergency medical | 14 | | transportation,
defined by the Department by rule,
shall be
| 15 | | conditional for 180 days. During that time, the Department of | 16 | | Healthcare and Family Services may
terminate the vendor's | 17 | | eligibility to participate in the medical assistance
program | 18 | | without cause. That termination of eligibility is not subject | 19 | | to the
Department's hearing process.
| 20 | | The Illinois Department shall establish policies, | 21 | | procedures,
standards and criteria by rule for the acquisition, | 22 | | repair and replacement
of orthotic and prosthetic devices and | 23 | | durable medical equipment. Such
rules shall provide, but not be | 24 | | limited to, the following services: (1)
immediate repair or | 25 | | replacement of such devices by recipients without
medical | 26 | | authorization; and (2) rental, lease, purchase or |
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| 1 | | lease-purchase of
durable medical equipment in a | 2 | | cost-effective manner, taking into
consideration the | 3 | | recipient's medical prognosis, the extent of the
recipient's | 4 | | needs, and the requirements and costs for maintaining such
| 5 | | equipment. Such rules shall enable a recipient to temporarily | 6 | | acquire and
use alternative or substitute devices or equipment | 7 | | pending repairs or
replacements of any device or equipment | 8 | | previously authorized for such
recipient by the Department.
| 9 | | The Department shall execute, relative to the nursing home | 10 | | prescreening
project, written inter-agency agreements with the | 11 | | Department of Human
Services and the Department on Aging, to | 12 | | effect the following: (i) intake
procedures and common | 13 | | eligibility criteria for those persons who are receiving
| 14 | | non-institutional services; and (ii) the establishment and | 15 | | development of
non-institutional services in areas of the State | 16 | | where they are not currently
available or are undeveloped.
| 17 | | The Illinois Department shall develop and operate, in | 18 | | cooperation
with other State Departments and agencies and in | 19 | | compliance with
applicable federal laws and regulations, | 20 | | appropriate and effective
systems of health care evaluation and | 21 | | programs for monitoring of
utilization of health care services | 22 | | and facilities, as it affects
persons eligible for medical | 23 | | assistance under this Code.
| 24 | | The Illinois Department shall report annually to the | 25 | | General Assembly,
no later than the second Friday in April of | 26 | | 1979 and each year
thereafter, in regard to:
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| 1 | | (a) actual statistics and trends in utilization of | 2 | | medical services by
public aid recipients;
| 3 | | (b) actual statistics and trends in the provision of | 4 | | the various medical
services by medical vendors;
| 5 | | (c) current rate structures and proposed changes in | 6 | | those rate structures
for the various medical vendors; and
| 7 | | (d) efforts at utilization review and control by the | 8 | | Illinois Department.
| 9 | | The period covered by each report shall be the 3 years | 10 | | ending on the June
30 prior to the report. The report shall | 11 | | include suggested legislation
for consideration by the General | 12 | | Assembly. The filing of one copy of the
report with the | 13 | | Speaker, one copy with the Minority Leader and one copy
with | 14 | | the Clerk of the House of Representatives, one copy with the | 15 | | President,
one copy with the Minority Leader and one copy with | 16 | | the Secretary of the
Senate, one copy with the Legislative | 17 | | Research Unit, and such additional
copies
with the State | 18 | | Government Report Distribution Center for the General
Assembly | 19 | | as is required under paragraph (t) of Section 7 of the State
| 20 | | Library Act shall be deemed sufficient to comply with this | 21 | | Section.
| 22 | | Rulemaking authority to implement Public Act 95-1045, if | 23 | | any, is conditioned on the rules being adopted in accordance | 24 | | with all provisions of the Illinois Administrative Procedure | 25 | | Act and all rules and procedures of the Joint Committee on | 26 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07; | 3 | | 95-1045, eff. 3-27-09; 96-156, eff. 1-1-10; 96-806, eff. | 4 | | 7-1-10; 96-926, eff. 1-1-11; 96-1000, eff. 7-2-10 .) | 5 | | (305 ILCS 5/5-26) | 6 | | Sec. 5-26. Federal Family Opportunity Act. | 7 | | (a) As used in this Section, "the federal Act" means the | 8 | | federal Family Opportunity Act, enacted as part of the Deficit | 9 | | Reduction Act of 2005.
| 10 | | (b) Subject to appropriations for program administration | 11 | | and services, the The Department of Human Services, in | 12 | | conjunction with the Department of Healthcare and Family | 13 | | Services, shall implement the Medical Assistance provisions of | 14 | | the federal Act as soon as possible after the effective date of | 15 | | this amendatory Act of the 95th General Assembly. | 16 | | (c) As soon as possible after the effective date of this | 17 | | amendatory Act of the 95th General Assembly, the Department of | 18 | | Human Services, in conjunction with the Department of | 19 | | Healthcare and Family Services, shall take all necessary and | 20 | | appropriate steps to try to secure (i) any available federal | 21 | | funds for a demonstration project regarding home and | 22 | | community-based alternatives to psychiatric residential | 23 | | treatment facilities for children, as authorized by the federal | 24 | | Act, and (ii) the location in Illinois of a family-to-family | 25 | | health information center, as authorized by the federal Act.
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| 1 | | (Source: P.A. 95-37, eff. 8-10-07.)
| 2 | | (305 ILCS 5/5A-9) (from Ch. 23, par. 5A-9)
| 3 | | Sec. 5A-9. Emergency services audits. The Illinois | 4 | | Department may
audit hospital claims for payment for emergency | 5 | | services provided to a
recipient who does not require admission | 6 | | as an inpatient. The Illinois
Department shall adopt rules that | 7 | | describe how the emergency services audit
process will be | 8 | | conducted. These rules shall include, but need not be
limited | 9 | | to, the following provisions:
| 10 | | (1) The determination that an emergency medical | 11 | | condition exists shall
be based upon the symptoms and | 12 | | condition of the recipient at the time the
recipient is | 13 | | initially examined by the hospital emergency department | 14 | | and
not upon the final determination of the recipient's | 15 | | actual medical condition.
| 16 | | (2) The Illinois Department or its authorized | 17 | | representative shall
meet with the chief executive officer | 18 | | of the hospital, or a person
designated by the chief | 19 | | executive officer, upon arrival at the hospital to
conduct | 20 | | the audit and before leaving the hospital at the conclusion | 21 | | of the
audit. The purpose of the pre-audit meeting shall be | 22 | | to inform the
hospital concerning the scope of the audit. | 23 | | The purpose of the post-audit
meeting shall be to provide | 24 | | the hospital with the preliminary findings of
the audit.
| 25 | | (3) An emergency services audit shall be limited to a |
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| 1 | | review of
records related to services rendered within 6 3 | 2 | | years of the date of the
audit. The hospital's business and | 3 | | professional records for at least 12
previous calendar | 4 | | months shall be maintained and available for inspection
by | 5 | | authorized Illinois Department personnel on the premises | 6 | | of the
hospital. Illinois Department personnel shall make | 7 | | requests in writing to
inspect records more than 12 months | 8 | | old at least 2 business days in advance
of the date they | 9 | | must be produced.
| 10 | | (4) Where the purpose of the audit is to determine the | 11 | | appropriateness
of the emergency services provided, any | 12 | | final determination that would
result in a denial of or | 13 | | reduction in payment to the hospital shall be made
by a | 14 | | physician licensed to practice medicine in all of its | 15 | | branches who is
board certified in emergency medicine or by | 16 | | the appropriate health care
professionals under the | 17 | | supervision of the physician.
| 18 | | (5) The preliminary audit findings shall be provided to | 19 | | the hospital
within 120 days of the date on which the audit | 20 | | conducted on the hospital
premises was completed.
| 21 | | (6) The Illinois Department or its designated review | 22 | | agent shall use
statistically valid sampling techniques | 23 | | when conducting audits.
| 24 | | (Source: P.A. 87-861.)
| 25 | | (305 ILCS 5/12-4.42)
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| 1 | | Sec. 12-4.42 12-4.40 . Medicaid Revenue Maximization. | 2 | | (a) Purpose. The General Assembly finds that there is a | 3 | | need to make changes to the administration of services provided | 4 | | by State and local governments in order to maximize federal | 5 | | financial participation. | 6 | | (b) Definitions. As used in this Section: | 7 | | "Community Medicaid mental health services" means all | 8 | | mental health services outlined in Section 132 of Title 59 of | 9 | | the Illinois Administrative Code that are funded through DHS, | 10 | | eligible for federal financial participation, and provided by a | 11 | | community-based provider. | 12 | | "Community-based provider" means an entity enrolled as a | 13 | | provider pursuant to Sections 140.11 and 140.12 of Title 89 of | 14 | | the Illinois Administrative Code and certified to provide | 15 | | community Medicaid mental health services in accordance with | 16 | | Section 132 of Title 59 of the Illinois Administrative Code. | 17 | | "DCFS" means the Department of Children and Family | 18 | | Services. | 19 | | "Department" means the Illinois Department of Healthcare | 20 | | and Family Services. | 21 | | "Developmentally disabled care facility" means an | 22 | | intermediate care facility for the mentally retarded within the | 23 | | meaning of Title XIX of the Social Security Act, whether public | 24 | | or private and whether organized for profit or not-for-profit, | 25 | | but shall not include any facility operated by the State. | 26 | | "Developmentally disabled care provider" means a person |
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| 1 | | conducting, operating, or maintaining a developmentally | 2 | | disabled care facility. For purposes of this definition, | 3 | | "person" means any political subdivision of the State, | 4 | | municipal corporation, individual, firm, partnership, | 5 | | corporation, company, limited liability company, association, | 6 | | joint stock association, or trust, or a receiver, executor, | 7 | | trustee, guardian, or other representative appointed by order | 8 | | of any court. | 9 | | "DHS" means the Illinois Department of Human Services. | 10 | | "Hospital" means an institution, place, building, or | 11 | | agency located in this State that is licensed as a general | 12 | | acute hospital by the Illinois Department of Public Health | 13 | | under the Hospital Licensing Act, whether public or private and | 14 | | whether organized for profit or not-for-profit. | 15 | | "Long term care facility" means (i) a skilled nursing or | 16 | | intermediate long term care facility, whether public or private | 17 | | and whether organized for profit or not-for-profit, that is | 18 | | subject to licensure by the Illinois Department of Public | 19 | | Health under the Nursing Home Care Act, including a county | 20 | | nursing home directed and maintained under Section 5-1005 of | 21 | | the Counties Code, and (ii) a part of a hospital in which | 22 | | skilled or intermediate long term care services within the | 23 | | meaning of Title XVIII or XIX of the Social Security Act are | 24 | | provided; except that the term "long term care facility" does | 25 | | not include a facility operated solely as an intermediate care | 26 | | facility for the mentally retarded within the meaning of Title |
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| 1 | | XIX of the Social Security Act. | 2 | | "Long term care provider" means (i) a person licensed by | 3 | | the Department of Public Health to operate and maintain a | 4 | | skilled nursing or intermediate long term care facility or (ii) | 5 | | a hospital provider that provides skilled or intermediate long | 6 | | term care services within the meaning of Title XVIII or XIX of | 7 | | the Social Security Act. For purposes of this definition, | 8 | | "person" means any political subdivision of the State, | 9 | | municipal corporation, individual, firm, partnership, | 10 | | corporation, company, limited liability company, association, | 11 | | joint stock association, or trust, or a receiver, executor, | 12 | | trustee, guardian, or other representative appointed by order | 13 | | of any court. | 14 | | "State-operated developmentally disabled care facility" | 15 | | means an intermediate care facility for the mentally retarded | 16 | | within the meaning of Title XIX of the Social Security Act | 17 | | operated by the State. | 18 | | (c) Administration and deposit of Revenues. The Department | 19 | | shall coordinate the implementation of changes required by this | 20 | | amendatory Act of the 96th General Assembly amongst the various | 21 | | State and local government bodies that administer programs | 22 | | referred to in this Section. | 23 | | Revenues generated by program changes mandated by any | 24 | | provision in this Section, less reasonable administrative | 25 | | costs associated with the implementation of these program | 26 | | changes, which would otherwise be deposited into the General |
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| 1 | | Revenue Fund shall be deposited into the Healthcare Provider | 2 | | Relief Fund. | 3 | | The Department shall issue a report to the General Assembly | 4 | | detailing the implementation progress of this amendatory Act of | 5 | | the 96th General Assembly as a part of the Department's Medical | 6 | | Programs annual report for fiscal years 2010 and 2011. | 7 | | (d) Acceleration of payment vouchers. To the extent | 8 | | practicable and permissible under federal law, the Department | 9 | | shall create all vouchers for long term care facilities and | 10 | | developmentally disabled care facilities for dates of service | 11 | | in the month in which the enhanced federal medical assistance | 12 | | percentage (FMAP) originally set forth in the American Recovery | 13 | | and Reinvestment Act (ARRA) expires and for dates of service in | 14 | | the month prior to that month and shall, no later than the 15th | 15 | | of the month in which the enhanced FMAP expires, submit these | 16 | | vouchers to the Comptroller for payment. | 17 | | The Department of Human Services shall create the necessary | 18 | | documentation for State-operated developmentally disabled care | 19 | | facilities so that the necessary data for all dates of service | 20 | | before the expiration of the enhanced FMAP originally set forth | 21 | | in the ARRA can be adjudicated by the Department no later than | 22 | | the 15th of the month in which the enhanced FMAP expires. | 23 | | (e) Billing of DHS community Medicaid mental health | 24 | | services. No later than July 1, 2011, community Medicaid mental | 25 | | health services provided by a community-based provider must be | 26 | | billed directly to the Department. |
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| 1 | | (f) DCFS Medicaid services. The Department shall work with | 2 | | DCFS to identify existing programs, pending qualifying | 3 | | services, that can be converted in an economically feasible | 4 | | manner to Medicaid in order to secure federal financial | 5 | | revenue. | 6 | | (g) Third Party Liability recoveries. The Department shall | 7 | | contract with a vendor to support the Department in | 8 | | coordinating benefits for Medicaid enrollees. The scope of work | 9 | | shall include, at a minimum, the identification of other | 10 | | insurance for Medicaid enrollees and the recovery of funds paid | 11 | | by the Department when another payer was liable. The vendor may | 12 | | be paid a percentage of actual cash recovered when practical | 13 | | and subject to federal law. | 14 | | (h) Public health departments.
The Department shall | 15 | | identify unreimbursed costs for persons covered by Medicaid who | 16 | | are served by the Chicago Department of Public Health. | 17 | | The Department shall assist the Chicago Department of | 18 | | Public Health in determining total unreimbursed costs | 19 | | associated with the provision of healthcare services to | 20 | | Medicaid enrollees. | 21 | | The Department shall determine and draw the maximum | 22 | | allowable federal matching dollars associated with the cost of | 23 | | Chicago Department of Public Health services provided to | 24 | | Medicaid enrollees. | 25 | | (i) Acceleration of hospital-based payments.
The | 26 | | Department shall, by the 10th day of the month in which the |
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| 1 | | enhanced FMAP originally set forth in the ARRA expires, create | 2 | | vouchers for all State fiscal year 2011 hospital payments | 3 | | exempt from the prompt payment requirements of the ARRA. The | 4 | | Department shall submit these vouchers to the Comptroller for | 5 | | payment.
| 6 | | (Source: P.A. 96-1405, eff. 7-29-10; revised 9-9-10.)
| 7 | | (305 ILCS 5/12-10.5)
| 8 | | Sec. 12-10.5. Medical Special Purposes Trust Fund.
| 9 | | (a) The Medical Special Purposes Trust Fund ("the Fund") is | 10 | | created.
Any grant, gift, donation, or legacy of money or | 11 | | securities that the
Department of Healthcare and Family | 12 | | Services is authorized to receive under Section 12-4.18 or
| 13 | | Section 12-4.19, and that is dedicated for functions connected | 14 | | with the
administration of any medical program administered by | 15 | | the Department, shall
be deposited into the Fund. All federal | 16 | | moneys received by the Department as
reimbursement for | 17 | | disbursements authorized to be made from the Fund shall also
be | 18 | | deposited into the Fund. In addition, federal moneys received | 19 | | on account
of State expenditures made in connection with | 20 | | obtaining compliance with the
federal Health Insurance | 21 | | Portability and Accountability Act (HIPAA) shall be
deposited | 22 | | into the Fund.
| 23 | | (b) No moneys received from a service provider or a | 24 | | governmental or private
entity that is enrolled with the | 25 | | Department as a provider of medical services
shall be deposited |
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| 1 | | into the Fund.
| 2 | | (c) Disbursements may be made from the Fund for the | 3 | | purposes connected with
the grants, gifts, donations, or | 4 | | legacies deposited into the Fund, including,
but not limited | 5 | | to, medical quality assessment projects, eligibility | 6 | | population
studies, medical information systems evaluations, | 7 | | and other administrative
functions that assist the Department | 8 | | in fulfilling its health care mission
under any medical program | 9 | | administered by the Department the Illinois Public Aid Code and | 10 | | the Children's Health Insurance Program
Act .
| 11 | | (Source: P.A. 95-331, eff. 8-21-07.)
| 12 | | (305 ILCS 5/5-2.4 rep.)
| 13 | | (305 ILCS 5/9A-9.5 rep.)
| 14 | | Section 20. The Illinois Public Aid Code is amended by | 15 | | repealing Sections 5-2.4 and 9A-9.5.
| 16 | | Section 99. Effective date. This Act takes effect upon | 17 | | becoming law.
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| 1 | |
INDEX
| 2 | |
Statutes amended in order of appearance
| | 3 | | 5 ILCS 100/5-70 | from Ch. 127, par. 1005-70 | | 4 | | 20 ILCS 10/Act rep. | | | 5 | | 30 ILCS 105/5.573 | | | 6 | | 30 ILCS 105/6z-58 | | | 7 | | 210 ILCS 45/2-201.5 | | | 8 | | 305 ILCS 5/5-2 | from Ch. 23, par. 5-2 | | 9 | | 305 ILCS 5/5-5 | from Ch. 23, par. 5-5 | | 10 | | 305 ILCS 5/5-26 | | | 11 | | 305 ILCS 5/5A-9 | from Ch. 23, par. 5A-9 | | 12 | | 305 ILCS 5/12-4.42 | | | 13 | | 305 ILCS 5/12-10.5 | | | 14 | | 305 ILCS 5/5-2.4 rep. | | | 15 | | 305 ILCS 5/9A-9.5 rep. | |
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