(305 ILCS 5/Art. I heading) ARTICLE I.
PUBLIC PURPOSE - SHORT
TITLE - PRIOR STATUTE - CONSTRUCTION
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(305 ILCS 5/1-1) (from Ch. 23, par. 1-1)
Sec. 1-1.
Public
purpose-Aims in providing financial aid and services. The purpose of this Code
is to assist in the alleviation and prevention
of poverty and thereby to protect and promote the health and welfare of all
the people of this State.
To accomplish this purpose, this Code authorizes financial aid and
social welfare services for persons in need thereof by reason of
unemployment, illness, or other cause depriving them of the means of a
livelihood compatible with health and well-being, and provides for the
development, use and coordination of all resources in this State,
governmental and private.
The Illinois Department
shall establish such standards of
financial aid and services as will encourage and assist applicants and
recipients to maintain a livelihood compatible with health and well being
and to develop their self-reliance and realize their capacities for
self-care, self-support, and responsible citizenship.
The maintenance and strengthening of the family unit shall be a
principal consideration in the administration of this Code. All public aid
policies shall be formulated and administered to achieve this end.
(Source: P.A. 89-507, eff. 7-1-97.)
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(305 ILCS 5/1-2) (from Ch. 23, par. 1-2)
Sec. 1-2.
Short title.
This Act may be cited as the
Illinois Public Aid Code.
(Source: P.A. 86-1475.)
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(305 ILCS 5/1-3) (from Ch. 23, par. 1-3)
Sec. 1-3.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/1-4) (from Ch. 23, par. 1-4)
Sec. 1-4.
Reference
to article.
Whenever reference is made in this Code to an Article or Articles, the
reference applies to an Article or Articles of this Code, unless the
context otherwise requires.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/1-5) (from Ch. 23, par. 1-5)
Sec. 1-5.
Construction.
The provisions of this Code shall be liberally construed to effect its
objects and purposes.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/1-6) (from Ch. 23, par. 1-6)
Sec. 1-6.
Notwithstanding any provisions of this Code to the contrary, a
person,
if eligible, shall be required to file for unemployment compensation
benefits as a condition for qualifying for public assistance benefits under
programs of aid to the aged, blind, or disabled, aid to families with
dependent children, and aid to families with dependent children--
unemployed, which are administered by the Illinois Department, or general
assistance programs administered by some other public
agency.
(Source: P.A. 89-507, eff. 7-1-97.)
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(305 ILCS 5/1-7) (from Ch. 23, par. 1-7)
Sec. 1-7.
(a) For purposes of determining eligibility for assistance
under this Code, the Illinois Department, County Departments, and local
governmental units shall exclude from consideration restitution payments,
including all income and resources derived therefrom, made to persons of
Japanese or Aleutian ancestry pursuant to the federal Civil Liberties Act
of 1988 and the Aleutian and Pribilof Island Restitution Act, P.L. 100-383.
(b) For purposes of any program or form of assistance where a person's
income or assets are considered in determining eligibility or level of
assistance, whether under this Code or another authority, neither the State
of Illinois nor any entity or person administering a program wholly or
partially financed by the State of Illinois or any of its political
subdivisions shall include restitution payments, including all income and
resources derived therefrom, made pursuant to the federal Civil Liberties
Act of 1988 and the Aleutian and Pribilof Island Restitution Act, P.L.
100-383, in the calculation of income or assets for determining eligibility
or level of assistance.
(c) For purposes of determining eligibility for or the amount of assistance
under this Code, except for the determination of eligibility for payments or
programs under the TANF employment, education, and training programs and the
Food Stamp
Employment and Training Program, the Illinois Department, County Departments,
and local governmental units shall exclude from consideration any financial
assistance received under any student aid program administered by an agency of
this State or the federal government, by a person who is enrolled as a
full-time or part-time student of any public or private university, college, or
community college in this State.
(d) For purposes of determining eligibility for or the amount of assistance under this Code, except for the determination of eligibility for payments or programs under the TANF employment, education, and training programs and the SNAP Employment and Training Program, the Illinois Department, County Departments, and local governmental units shall exclude from consideration, for a period of 36 months, any financial assistance, including wages, that is provided to a person who is enrolled in a demonstration project that is not funded with general revenue funds and that is intended as a bridge to self-sufficiency by offering (i) intensive workforce support and training and (ii) support services for new and expectant parents that are intended to foster multi-generational healthy families as described in Section 12-4.51. (e)(1) Notwithstanding any other provision of this Code, and to the maximum extent permitted by federal law, for purposes of determining eligibility and the amount of assistance under this Code, the Illinois Department and local governmental units shall exclude from consideration any financial assistance, including cash transfers or gifts, that is provided to a person through a guaranteed income program. As used in this subsection, "guaranteed income program" means a publicly or privately funded program that provides one-time or recurring unconditional cash transfers or payments, or gifts to individuals or households, for a defined number of months or years for the purposes of reducing poverty, promoting economic mobility, or increasing the financial stability of Illinois residents. (2) The Department shall choose State options and seek all necessary federal approvals or waivers to implement this subsection. (Source: P.A. 103-492, eff. 1-1-24.)
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(305 ILCS 5/1-8)
Sec. 1-8. Fugitives ineligible.
(a) The following persons are not eligible for aid under this Code, or
federal food stamps or federal food stamp benefits:
(1) A person who has fled from the jurisdiction of | ||
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(2) A person who has fled to avoid imprisonment in a | ||
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(3) A person who has escaped from a correctional | ||
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(4) A person who is violating a condition of | ||
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In this Section, "felony" means a violation of a penal statute of this or any
other state or the United States for which a sentence to a term of
imprisonment in a penitentiary for one year or more is provided or in which the death penalty may be imposed in another state.
To implement this Section, the Illinois Department may exchange necessary
information with an appropriate law enforcement agency of this or any other
state, a political subdivision of this or any other state, or the United
States.
(b) (Blank).
(Source: P.A. 103-51, eff. 1-1-24.)
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(305 ILCS 5/1-8.5) Sec. 1-8.5. Eligibility for medical assistance during periods of incarceration or detention. (a) To the extent permitted by federal law and notwithstanding any other provision of this Code, the Department of Healthcare and Family Services shall not cancel a person's eligibility for medical assistance, nor shall the Department deny a person's application for medical assistance, solely because that person has become or is an inmate of a public institution, including, but not limited to, a county jail, juvenile detention center, or State correctional facility. The person may be and remain enrolled for medical assistance as long as all other eligibility criteria are met. (b) The Department may adopt rules to permit a person to apply for medical assistance while he or she is an inmate of a public institution as described in subsection (a). The rules may limit applications to persons who would be likely to qualify for medical assistance if they resided in the community. Any such person who is not already enrolled for medical assistance may apply for medical assistance prior to the date of scheduled release or discharge from a penal institution or county jail or similar status. (c) Except as provided under Section 17 of the County Jail Act, the Department shall not be responsible to provide medical assistance under this Code for any medical care, services, or supplies provided to a person while he or she is an inmate of a public institution as described in subsection (a). The responsibility for providing medical care shall remain as otherwise provided by law with the Department of Corrections, county, or other arresting authority. The Department may seek federal financial participation, to the extent that it is available and with the cooperation of the Department of Juvenile Justice, the Department of Corrections, or the relevant county, for the costs of those services. (d) To the extent permitted under State and federal law, the Department shall develop procedures to expedite required periodic reviews of continued eligibility for persons described in subsection (a). (e) Counties, the Department of Juvenile Justice, the Department of Human Services, and the Department of Corrections shall cooperate with the Department in administering this Section. That cooperation shall include managing eligibility processing and sharing information sufficient to inform the Department, in a manner established by the Department, that a person enrolled in the medical assistance program has been detained or incarcerated. (f) The Department shall resume responsibility for providing medical assistance upon release of the person to the community as long as all of the following apply: (1) The person is enrolled for medical assistance at | ||
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(2) Neither a county, the Department of Juvenile | ||
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(3) The county, the Department of Juvenile Justice, | ||
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(g) This Section applies on and after December 31, 2011.
(Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.) |
(305 ILCS 5/1-9)
Sec. 1-9.
Misrepresentation of residence.
A person who has been convicted
in federal or State court of having made a fraudulent statement or
representation with respect to residence in order to receive assistance
simultaneously from 2 or more states shall be ineligible for cash assistance
under this Code for 10 years beginning on the date of conviction.
(Source: P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/1-10)
Sec. 1-10. Drug convictions.
(a) Persons convicted of an offense under the Illinois Controlled Substances
Act, the Cannabis Control Act, or the Methamphetamine Control and Community Protection Act which is a Class X felony, or a Class 1 felony,
or comparable federal criminal law which has as an element the
possession, use, or distribution of a controlled substance, as defined in
Section 102(6) of the federal Controlled Substances Act (21 U.S.C. 802(c)),
shall not be eligible for cash assistance provided under this Code.
(b) Persons convicted of
any other felony under the Illinois Controlled Substances Act, the Cannabis
Control Act, or the Methamphetamine Control and Community Protection Act which is not a Class X or Class 1 felony, or comparable
federal criminal law which has as an element the possession, use, or
distribution of a
controlled substance, as defined in Section 102(6) of the federal Controlled
Substances Act (21 U.S.C. 802(c)), shall not be eligible for cash assistance
provided under this Code for 2 years from the date of conviction. This
prohibition shall not apply if the person is in a drug treatment program,
aftercare program, or similar program as defined by rule.
(c) Persons shall not be determined ineligible for food stamps provided
under this Code based upon a conviction of any felony or comparable federal or
State criminal law which has an element the possession, use or distribution of
a controlled substance, as defined in Section 102(6) of the federal Controlled Substances
Act (21 U.S.C. 802(c)).
(d) Notwithstanding any other provision of this Section to the contrary, persons shall not be determined ineligible for cash assistance provided under Article IV or Article VI of this Code based upon a conviction for any drug-related felony under State or federal law. (Source: P.A. 102-178, eff. 10-30-21; 103-192, eff. 1-1-24.)
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(305 ILCS 5/1-11)
Sec. 1-11. Citizenship. To the extent not otherwise provided in this Code
or federal law, all clients who receive cash or medical assistance under
Article III, IV, V, or VI of this
Code must meet the citizenship requirements as established in this Section.
To be eligible for assistance an individual, who is otherwise eligible, must be
either a United
States citizen or included in one of the following categories of
non-citizens:
(1) United States veterans honorably discharged and | ||
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(2) Refugees under Section 207 of the Immigration and | ||
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(3) Asylees under Section 208 of the Immigration and | ||
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(4) Persons for whom deportation has been withheld | ||
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(5) Persons granted conditional entry under Section | ||
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(6) Persons lawfully admitted for permanent residence | ||
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(7) Parolees, for at least one year, under Section | ||
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(8) Nationals of Cuba or Haiti admitted on or after | ||
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(9) Amerasians from Vietnam, and their close family | ||
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(10) Persons identified by the federal Office of | ||
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(11) Persons legally residing in the United States | ||
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(12) American Indians born in Canada under Section | ||
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(13) Persons who are a spouse, widow, or child of a | ||
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(14) Persons who are foreign-born victims of | ||
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Those persons who are in the categories set forth in subdivisions 6 and 7
of this Section, who enter the United States on or
after August 22,
1996, shall not be eligible for 5 years beginning on the date the person
entered the United States.
The Illinois Department may, by rule, cover prenatal care or emergency
medical care for non-citizens who are not otherwise eligible under this
Section.
Local governmental units which do not receive State funds may impose their
own
citizenship requirements and are authorized to provide any benefits and impose
any citizenship requirements as are allowed under the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193).
(Source: P.A. 99-870, eff. 8-22-16.)
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(305 ILCS 5/1-12) Sec. 1-12. Providing information to the State Board of Elections. The Secretary of the Department of Human Services and the Director of the Department of Healthcare and Family Services shall make information available, except where prohibited by federal law or regulation, to the State Board of Elections as may be required by an agreement the State Board of Elections has entered into with a multi-state voter registration list maintenance system.
(Source: P.A. 98-1171, eff. 6-1-15.) |
(305 ILCS 5/Art. II heading) ARTICLE II.
DEFINITIONS
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(305 ILCS 5/2-1) (from Ch. 23, par. 2-1)
Sec. 2-1.
Definitions.
The terms defined in this Article shall have the meanings ascribed to
them, except when the context otherwise requires.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-2) (from Ch. 23, par. 2-2)
Sec. 2-2.
"Public
aid".
Financial aid and all rehabilitative and other services provided under
this Code for basic maintenance support; medical, surgical, dental,
pharmaceutical, optometric, or nursing services, or other remedial care
recognized under State law; rehabilitative services; education, training or
retraining for employment or self-support work; funeral and burial
expenses; and such other care and services as are determined to be
necessary in each case.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-3) (from Ch. 23, par. 2-3)
Sec. 2-3.
"Money payment" or "grant".
A payment made direct to the recipient, his legal representative, or
other substitute payee by warrant, check, direct deposit transmittal
or other instrument for basic
maintenance support or other purpose.
(Source: P.A. 82-391.)
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(305 ILCS 5/2-4) (from Ch. 23, par. 2-4)
Sec. 2-4.
"Grantee"
or "payee".
The person to whom a money payment is made.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-5) (from Ch. 23, par. 2-5)
Sec. 2-5.
"Vendor
payment".
A payment made directly to the person, firm, corporation, association,
agency, institution or other legal entity supplying goods or services to a
recipient.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-6) (from Ch. 23, par. 2-6)
Sec. 2-6.
"Financial aid".
A money or vendor payment to or in behalf of a recipient for basic
maintenance support or medical assistance provided under Articles III, IV,
V, and VI.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/2-7) (from Ch. 23, par. 2-7)
Sec. 2-7.
"Social services":
assistance, other than financial aid, provided
under Article IX.
(Source: P.A. 82-440.)
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(305 ILCS 5/2-8) (from Ch. 23, par. 2-8)
Sec. 2-8.
"Applicant":
A person who has applied for financial aid under any of the
provisions of this Code.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-9) (from Ch. 23, par. 2-9)
Sec. 2-9.
"Recipient":
A person who is receiving financial aid under any
of the provisions of this Code.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/2-10) (from Ch. 23, par. 2-10)
Sec. 2-10.
"Residence": The establishment of a permanent home within this State.
A person is deemed to have established his permanent home within this
State if he has acquired by purchase, rental, or other arrangement housing
facilities which he uses as his home; has located his household equipment,
furnishings and personal belongings therein; and is or has been employed,
is seeking employment, or is engaged in other self-support activity, in the
community in which he lives or within a distance reasonably proximate
thereto, within or without the State, which is accessible to his home by
public or private transportation facilities and to which he regularly
commutes, or, if he cannot engage in employment or other self-support
activity, is maintained in such home by relatives responsible for his
support or by other sources or means of maintenance and support. A person
shall not be required to occupy a permanent dwelling or have a fixed home
or mailing address in order to establish a permanent home within this State.
However, a recipient who moves from this State for the purpose of
obtaining employment or other means of support or care shall retain his
residence eligibility for a period of 12 months, provided he has not
acquired residence eligibility for public aid under the laws of any
State to which he has moved.
The residence of a married woman shall be that of her husband unless
they are living separate and apart, in which case she may acquire a
separate residence.
Minor children shall have the residence of their father if they
reside with him; if they reside with their mother they shall have her
residence.
A minor, neither of whose parents has acquired a residence, may
acquire a residence as if he or she were a person of full age.
Every minor upon marriage may acquire a residence as if he or she
were a person of full age.
Applicants for or recipients of public aid shall meet such durational
requirements as to residence as may be specified in the Article
governing the category under which they are applying for or receiving aid.
Temporary absence from the State, absence while in the service of the
State or Nation, or entry into a hospital or other medical care
institution outside the State for medical treatment, shall not affect a
person's residence.
A recipient of aid under Article III, IV or VI who, for any reason,
has remained outside the State for a continuous period of more than 12
months shall prima facie be presumed to have lost his residence and
shall receive no further aid unless and until he submits evidence
sufficient to prove he has retained his residence. If the evidence
proves that the absence was without intention to change his residence,
the recipient shall be deemed to have maintained his residence
eligibility and the grant of aid shall be continued or resumed.
(Source: P.A. 85-1231.)
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(305 ILCS 5/2-11) (from Ch. 23, par. 2-11)
Sec. 2-11.
"Family Unit": Husband and wife and a child or children under age 21.
Spouses and parents of children under
age 21 constitute "legally responsible relatives" or "responsible relatives" wherever
those terms may be used in this Code in respect to their support
obligation enforceable by court action or an administrative order of the
Illinois Department, as provided in Article X, or enforceable through other
State or Federal laws.
The support obligation of other persons defined as "legally responsible
relatives" in this Section prior to October 6, 1969
for aid extended to their
dependents prior to that date shall remain unimpaired.
(Source: P.A. 79-474.)
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(305 ILCS 5/2-12) (from Ch. 23, par. 2-12) Sec. 2-12. "Illinois Department"; "Department". In this Code, "Illinois Department" or "Department", when a particular entity is not specified, means the following: (1) In the case of a function performed before July | ||
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(2) Except as provided in paragraph (2.5), in the | ||
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(2.5) In the case of a function to be performed on or | ||
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(3) In the case of a function to be performed on or | ||
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(4) In the case of a function to be performed on or | ||
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(Source: P.A. 103-594, eff. 6-25-24.) |
(305 ILCS 5/2-12.5) Sec. 2-12.5. "Director of the Illinois Department"; "Director of the Department"; "Director". In this Code, "Director of the Illinois Department", "Director of the Department", or "Director", when a particular official is not specified, means the following: (1) In the case of a function performed before July | ||
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(2) Except as provided in paragraph (2.5), in the | ||
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(2.5) In the case of a function to be performed on or | ||
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(3) In the case of a function to be performed on or | ||
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(4) In the case of a function to be performed on or | ||
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(Source: P.A. 103-594, eff. 6-25-24.) |
(305 ILCS 5/2-13) (from Ch. 23, par. 2-13)
Sec. 2-13.
"County department".
The Department of Human Services local office or offices in each county in this
State.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/2-14) (from Ch. 23, par. 2-14)
Sec. 2-14. "Local governmental unit". Every county, city, village,
incorporated town or township charged with the duty of providing public
aid under Article VI; and County Veterans Assistance Commissions
providing general assistance to veterans and their families
under Section 12-21.13 of Article XII.
However, should any Section of this Code impose the obligation of
providing medical assistance to persons who are non-residents of the
State of Illinois upon a local governmental unit, the term "local
governmental unit" shall not include townships. In such case the
obligation for providing medical assistance to non-residents which would
otherwise be the duty of a township shall become the obligation of the
Department of Healthcare and Family Services.
(Source: P.A. 102-732, eff. 1-1-23.)
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(305 ILCS 5/2-15) (from Ch. 23, par. 2-15)
Sec. 2-15.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/2-16) (from Ch. 23, par. 2-16)
Sec. 2-16.
"Service provider":
A person or corporation who furnishes
medical, educational, psychiatric, vocational or rehabilitative services
to a recipient under this Code, but excluding an employee of the Illinois
Department or a County Department.
(Source: P.A. 82-555.)
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(305 ILCS 5/2-17) (from Ch. 23, par. 2-17)
Sec. 2-17.
"Unable to purchase care and maintenance":
For the
purposes of this Code and Division 5-21 of the Counties Code, a person
receiving Medical Assistance under this Code shall not be deemed "unable to
purchase care and maintenance".
(Source: P.A. 86-1475.)
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(305 ILCS 5/2-18)
Sec. 2-18. Domestic or sexual violence. "Domestic or sexual violence" means domestic violence, sexual assault, or stalking. Domestic or sexual violence may occur through electronic communication. "Domestic violence" means "abuse" as defined in Section 103 of the Illinois Domestic Violence Act of 1986 by a "family or household member" as defined in Section 103 of the Illinois Domestic Violence Act of 1986. "Sexual assault" means any conduct proscribed by Sections 11-1.20, 11-1.30, 11-1.40, 11-1.50, 11-1.60, 12-13, 12-14, 12-14.1, 12-15, and 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012. "Stalking" means any conduct proscribed by Sections 12-7.3, 12-7.4, and 12-7.5 of the Criminal Code of 1961 or the Criminal Code of 2012. "Electronic communication" includes communications via telephone, mobile phone, computer, e-mail, video recorder, fax machine, telex, or pager, or any other "electronic communication" as defined in Section 12-7.5 of the Criminal Code of 2012.
(Source: P.A. 96-866, eff. 7-1-10; 97-1150, eff. 1-25-13.) |
(305 ILCS 5/2-19) Sec. 2-19. Foreign-born victims of trafficking, torture, or other serious crimes. "Foreign-born victim of trafficking, torture, or other serious crimes" means a person who is: (1) a non-citizen victim of a severe form of | ||
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(2) a non-citizen victim of an act or practice | ||
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(3) a non-citizen who has a well-founded fear of | ||
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(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/Art. III heading) ARTICLE III.
AID TO THE AGED, BLIND
OR DISABLED
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(305 ILCS 5/3-1) (from Ch. 23, par. 3-1)
Sec. 3-1. Eligibility Requirements. Financial aid in meeting basic
maintenance requirements for a livelihood compatible with health and
well-being shall be given under this Article to or in behalf of aged,
blind, or disabled persons who meet the eligibility conditions of Sections
3-1.1 through 3-1.7. Financial aid under this Article shall be available only
for persons who are receiving Supplemental Security Income (SSI) or who have
been found ineligible for SSI (i) on the basis of income or (ii) due to expiration of the period of eligibility for refugees and asylees pursuant to 8 U.S.C. 1612(a)(2).
"Aged person" means a person who has attained age 65, as demonstrated by
such evidence of age as the Illinois Department may by rule prescribe.
"Blind person" means a person who has no vision or whose vision with
corrective glasses is so defective as to prevent the performance of
ordinary duties or tasks for which eyesight is essential. The Illinois
Department shall define blindness in terms of ophthalmic measurements or
ocular conditions. For purposes of this Act, an Illinois Person
with a Disability Identification Card issued pursuant to the Illinois Identification Card
Act, indicating that the person thereon named has a Type 3 disability shall
be evidence that such person is a blind person within the meaning of this
Section; however, such a card shall not qualify such person for aid as a
blind person under this Act, and eligibility for aid as a blind person
shall be determined as provided in this Act.
"Disabled person" means a person age 18 or over who has a physical or
mental impairment, disease, or loss which is of a permanent nature and
which substantially impairs his ability to perform labor or services or to
engage in useful occupations for which he is qualified, as determined by
rule and regulation of the Illinois Department. For purposes of this
Act, an Illinois Person with a Disability Identification Card issued pursuant to the
Illinois Identification Card Act, indicating that the person thereon named
has a Type 1 or 2, Class 2 disability shall be evidence that such person is
a disabled person under this Section; however, such a card shall not
qualify such person for aid as a disabled person under this Act, and
eligibility for aid as a disabled person shall be determined as provided in
this Act. If federal law or regulation permit or require the inclusion of
blind or disabled persons whose blindness or disability is not of the
degree specified in the foregoing definitions, or permit or require the
inclusion of disabled persons under age 18 or aged persons under age 65,
the Illinois Department, upon written approval of the Governor, may provide
by rule that all aged, blind or disabled persons toward whose aid federal
funds are available be eligible for assistance under this Article as is
given to those who meet the foregoing definitions of blind person and
disabled person or aged person.
(Source: P.A. 96-22, eff. 6-30-09; 97-1064, eff. 1-1-13.)
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(305 ILCS 5/3-1a) (from Ch. 23, par. 3-1a)
Sec. 3-1a.
Interim Assistance.
(a) (Blank).
(b) The Illinois Department may establish, by rule, an advocacy program to
help clients pursue Supplemental Security Income applications and, if the
client is found ineligible for Supplemental Security Income initially, to help
the client pursue the Supplemental Security Income reconsideration and appeal
process. This program may be limited to specific geographic areas.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/3-1.2) (from Ch. 23, par. 3-1.2)
Sec. 3-1.2. Need. (a) Income available to the person, when added to
contributions in money, substance, or services from other sources,
including contributions from legally responsible relatives, must be
insufficient to equal the grant amount established by Department regulation
for such person. In determining earned income to be taken into account, consideration
shall be given to any expenses reasonably attributable to the earning of
such income. If federal law or regulations permit or require exemption
of earned or other income and resources, the Illinois Department shall
provide by rule and regulation that the amount of income to be
disregarded be increased (1) to the maximum extent so required and (2)
to the maximum extent permitted by federal law or regulation in effect
as of the date this amendatory Act becomes law. The Illinois Department
may also provide by rule and regulation that the amount of resources to
be disregarded be increased to the maximum extent so permitted or required. (b) Subject to federal approval, resources (for example, land, buildings, equipment, supplies, or tools), including farmland property and personal property used in the income-producing operations related to the farmland (for example, equipment and supplies, motor vehicles, or tools), necessary for self-support, up to $6,000 of the person's equity in the income-producing property, provided that the property produces a net annual income of at least 6% of the excluded equity value of the property, are exempt. Equity value in excess of $6,000 shall not be excluded. If the activity produces income that is less than 6% of the exempt equity due to reasons beyond the person's control (for example, the person's illness or crop failure) and there is a reasonable expectation that the property will again produce income equal to or greater than 6% of the equity value (for example, a medical prognosis that the person is expected to respond to treatment or that drought-resistant corn will be planted), the equity value in the property up to $6,000 is exempt. If the person owns more than one piece of property and each produces income, each piece of property shall be looked at to determine whether the 6% rule is met, and then the amounts of the person's equity in all of those properties shall be totaled to determine whether the total equity is $6,000 or less. The total equity value of all properties that is exempt shall be limited to $6,000.
(c) In determining the resources of an individual or any dependents, the
Department shall exclude from consideration the value of funeral and burial
spaces, funeral and
burial insurance the proceeds of which can only be used to pay the funeral
and burial expenses of the insured and funds specifically set aside for the
funeral and burial arrangements of the individual or his or her dependents,
including prepaid funeral and burial plans, to the same extent that such
items are excluded from consideration under the federal Supplemental
Security Income program (SSI). At any time prior to or after submitting an application for medical assistance and before a final determination of eligibility has been made by the Department, an applicant may use available resources to purchase one of the prepaid funeral or burial contracts exempted under this Section. Prepaid funeral or burial contracts are exempt to the following extent:
(1) Funds in a revocable prepaid funeral or | ||
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(2) Funds in an irrevocable prepaid funeral or | ||
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(3) A prepaid, guaranteed-price funeral or | ||
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(4) Existing life insurance policies are exempt if | ||
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(d) Notwithstanding any other provision of this Code to the contrary, an irrevocable trust containing the resources of a person who is determined to have a disability shall be considered exempt from consideration. A pooled trust must be established and managed by a non-profit association that pools funds but maintains a separate account for each beneficiary. The trust may be established by the person, a parent, grandparent, legal guardian, or court. It must be established for the sole benefit of the person and language contained in the trust shall stipulate that any amount remaining in the trust (up to the amount expended by the Department on medical assistance) that is not retained by the trust for reasonable administrative costs related to wrapping up the affairs of the subaccount shall be paid to the Department upon the death of the person. After a person reaches age 65, any funding by or on behalf of the person to the trust shall be treated as a transfer of assets for less than fair market value unless the person is a ward of a county public guardian or the State Guardian pursuant to Section 13-5 of the Probate Act of 1975 or Section 30 of the Guardianship and Advocacy Act and lives in the community, or the person is a ward of a county public guardian or the State Guardian pursuant to Section 13-5 of the Probate Act of 1975 or Section 30 of the Guardianship and Advocacy Act and a court has found that any expenditures from the trust will maintain or enhance the person's quality of life. If the trust contains proceeds from a personal injury settlement, any Department charge must be satisfied in order for the transfer to the trust to be treated as a transfer for fair market value. (e) The homestead shall be exempt from consideration except to the extent
that it meets the income and shelter needs of the person. "Homestead"
means the dwelling house and contiguous real estate owned and occupied
by the person, regardless of its value. Subject to federal approval, a person shall not be eligible for long-term care services, however, if the person's equity interest in his or her homestead exceeds the minimum home equity as allowed and increased annually under federal law. Subject to federal approval, on and after the effective date of this amendatory Act of the 97th General Assembly, homestead property transferred to a trust shall no longer be considered homestead property.
(f) Occasional or irregular gifts in cash, goods or services from persons
who are not legally responsible relatives which are of nominal value or
which do not have significant effect in meeting essential requirements
shall be disregarded. (g) The eligibility of any applicant for or recipient
of public aid under this Article is not affected by the payment of any
grant under the "Senior Citizens and Disabled Persons Property Tax
Relief Act" or any distributions or items of
income described under subparagraph (X) of paragraph (2) of subsection (a) of
Section 203 of the Illinois Income Tax Act.
(h) The Illinois Department may, after appropriate investigation, establish
and implement a consolidated standard to determine need and eligibility
for and amount of benefits under this Article or a uniform cash supplement
to the federal Supplemental Security Income program for all or any part
of the then current recipients under this Article; provided, however, that
the establishment or implementation of such a standard or supplement shall
not result in reductions in benefits under this Article for the then current
recipients of such benefits.
(i) The provisions under paragraph (4) of subsection (c) are subject to federal approval. The Department of Healthcare and Family Services shall apply for any necessary federal waivers or approvals to implement by January 1, 2023 the changes made to this Section by this amendatory Act of the 102nd General Assembly. (Source: P.A. 102-959, eff. 5-27-22.)
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(305 ILCS 5/3-1.3) (from Ch. 23, par. 3-1.3)
Sec. 3-1.3.
Property transfers.
To the extent required under federal law, a person
shall not make
or have
made a voluntary or involuntary
assignment or transfer of any legal or equitable interests in real or
personal property, whether vested, contingent or inchoate, for less than fair
market value.
(Source: P.A. 88-554, eff. 7-26-94.)
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(305 ILCS 5/3-1.4) (from Ch. 23, par. 3-1.4)
Sec. 3-1.4.
Residents of public institutions.
Residents of municipal,
county, state or national institutions for persons with mental illness or
persons with a developmental disability or for the tuberculous, or residents of
a home or other institution maintained by such governmental bodies when not in
need of institutional care because of sickness, convalescence, infirmity, or
chronic illness, and inmates of penal or correctional institutions maintained
by such governmental bodies, may qualify for aid under this Article only after
they have ceased to be residents or inmates, but they may apply in advance of
their discharge. Applications received from residents scheduled for discharge
from such institutions shall be processed by the Department in an expeditious
manner. For persons whose applications are approved, the date of eligibility
shall be the date of release from the institution.
A person shall not be deemed a resident of a State institution for persons
with mental illness or persons with a developmental disability within the
meaning of this Section if he or she has been conditionally discharged by
the Department of Mental Health and Developmental Disabilities or the
Department of Human Services (acting as successor to the Department of Mental
Health and Developmental Disabilities) and is no longer residing in the
institution.
Recipients of benefits under this Article who become residents of such
institutions shall be permitted a period of up to 30 days in such
institutions without suspension or termination of eligibility; if residency
in an institution extends beyond 30 days the eligibility for all benefits
except Aid to Families with Dependent Children shall be suspended.
Benefits shall be restored, effective on the date of discharge or release,
for persons who are residents of institutions. Within a reasonable time
after the discharge of a person who was a resident of an institution, the
Department shall redetermine the eligibility of such person.
The Department shall provide for procedures to expedite the determination of
disability of persons scheduled to be discharged from facilities operated
by the Department.
If federal law or regulations governing grants under this Article permit
the inclusion of persons who are residents of institutions designated in
this Section beyond the period authorized herein, the Illinois Department, upon
a determination that the appropriations for public aid are sufficient for such
purpose, and upon approval of the Governor, may provide by general and uniform
rule for the waiver of the provisions of this Section which would otherwise
disqualify such person for aid under this Article.
(Source: P.A. 88-380; 89-507, eff. 7-1-97.)
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(305 ILCS 5/3-1.5) (from Ch. 23, par. 3-1.5)
Sec. 3-1.5.
Residents of private institutions.
Persons who are residents of or who are being maintained by a private
institution may qualify only if they have not purchased care and
maintenance in the institution by cash or by transfer of property, or
having purchased care and maintenance, only after the amount of the cash or
property has been wholly consumed for care and maintenance.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/3-1.6) (from Ch. 23, par. 3-1.6)
Sec. 3-1.6.
(Repealed).
(Source: P.A. 77-1802. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/3-1.7) (from Ch. 23, par. 3-1.7)
Sec. 3-1.7.
Multiple convictions for violations of this Code.
Any person
found guilty of a second violation of Article VIIIA shall be ineligible
for financial aid under this Article, as provided in Section 8A-8.
(Source: P.A. 82-440.)
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(305 ILCS 5/3-2) (from Ch. 23, par. 3-2)
Sec. 3-2.
Conditions for basic maintenance grants to persons receiving institutional
care.
A resident of a public or private home or institution maintained for the
care of persons who are sick, convalescent, infirm or chronically ill, may,
if otherwise qualified, be granted financial aid for basic maintenance,
subject to the rules and regulations of the Illinois Department, if the
facilities of the home or institution are in conformity with standards
prescribed by the Department of Public Health for safeguarding the health,
safety, and comfort of the residents thereof, and provide such services as
may be prescribed by the Illinois Department for enhancing their
rehabilitation or increasing their capacity for self-care.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/3-2.5)
Sec. 3-2.5. (Repealed).
(Source: P.A. 93-774, eff. 7-21-04. Repealed by P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/3-2.6) Sec. 3-2.6. Sheltered care rates. The Department of Human Services shall increase the sheltered care rates in effect on June 30, 2022, by 10%.
(Source: P.A. 102-699, eff. 4-19-22.) |
(305 ILCS 5/3-3) (from Ch. 23, par. 3-3)
Sec. 3-3.
Examination as to blindness.
For all purposes, the Illinois Department may accept determinations as
to blindness performed under the auspices of the Federal Social Security
Administration and properly certified to the Department.
(Source: P.A. 89-21, eff. 7-1-95.)
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(305 ILCS 5/3-4) (from Ch. 23, par. 3-4)
Sec. 3-4.
Examination as to disability.
For all purposes, the Illinois Department may accept determinations
as to disability performed under the auspices of the Federal Social
Security Administration and properly certified to the Department.
(Source: P.A. 89-21, eff. 7-1-95.)
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(305 ILCS 5/3-5) (from Ch. 23, par. 3-5)
Sec. 3-5. Amount of aid. The amount and nature of financial aid granted
to or in behalf of aged, blind, or disabled persons shall be determined
in accordance with the standards, grant amounts, rules and regulations of
the Illinois Department. Due regard shall be given to the requirements
and conditions existing in each case, and to the amount of property
owned and the income, money contributions, and other support, and
resources received or obtainable by the person, from whatever source.
However, the amount and nature of any financial aid is not affected by
the payment of any grant under the "Senior Citizens and Disabled Persons
Property Tax Relief Act" or any distributions
or items of income described under subparagraph (X) of paragraph (2) of
subsection (a) of Section 203 of the Illinois Income Tax Act. The aid shall
be sufficient, when added to all other income, money contributions and
support, to provide the person with a grant in the amount established by
Department regulation for such a person, based upon standards providing a
livelihood compatible with health and well-being. Financial aid under this Article granted to persons who have been found ineligible for Supplemental Security Income (SSI) due to expiration of the period of eligibility for refugees and asylees pursuant to 8 U.S.C. 1612(a)(2) shall equal 90% of the current maximum SSI payment amount per month.
(Source: P.A. 97-689, eff. 6-14-12; 98-674, eff. 6-30-14.)
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(305 ILCS 5/3-5a) (from Ch. 23, par. 3-5a)
Sec. 3-5a.
Protective payments to substitute payee.
If the person, by reason of his physical or mental condition, is unable
to manage funds, or if, for any reason, he persistently mismanages the
grant to the detriment of his best interests, the County Department, in
accordance with the rules and regulations of the Illinois Department, may
make a protective payment by designating a person who is interested in or
concerned with the person's welfare to receive the grant in his behalf.
The substitute payee shall serve without compensation and assume the
obligation of seeing that the grant is expended for the recipient's
benefit. He may spend the grant for the recipient, or supervise the
recipient in its use, depending upon the circumstances in the case, and
shall make such monthly reports to the County Department as the County
Department and the Illinois Department may require.
The County Department shall terminate the protective payment when it has
made a determination that the grant will be used for the recipient's
welfare.
A substitute payee may be removed, in accordance with the rules and
regulations of the Illinois Department, for unsatisfactory service. Such
removal may be effected without hearing. The decision shall not be
appealable to the Illinois Department nor shall it be reviewable in the
courts.
The County Department shall conduct such periodic reviews as may be
required by the Illinois Department to determine whether there is a
continuing need for a protective payment. If it appears that the need for
such payment is likely to continue beyond a reasonable period, the County
Department shall take action for appointment by the circuit court of a
guardian or legal representative for the purpose of receiving and managing
the public aid grant.
The person shall be advised, in advance of a determination to make a
protective payment, that he may appeal the decision to the Illinois
Department under the provisions of Section 11-8 of Article XI.
(Source: Laws 1967, p. 2324.)
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(305 ILCS 5/3-6) (from Ch. 23, par. 3-6)
Sec. 3-6.
Entitlement to medical assistance.
Persons qualified for financial aid for basic maintenance shall be
entitled to receive, under Article V, all necessary medical assistance.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/3-7) (from Ch. 23, par. 3-7)
Sec. 3-7.
Entitlement to Social Services.
Persons qualified for financial
aid for basic maintenance shall be entitled to receive, under Article
IX, such rehabilitative, training or other social
services as are appropriate.
(Source: P.A. 82-440.)
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(305 ILCS 5/3-8) (from Ch. 23, par. 3-8)
Sec. 3-8.
Funeral and burial.
If the estate of a deceased recipient is insufficient to pay for funeral
and burial expenses, and if no other resources, including assistance from
legally responsible relatives, are available for such purposes, there shall
be paid, in accordance with the standards, rules and regulations of the
Illinois Department, such reasonable amounts as may be necessary to meet
costs of the funeral, burial space, and cemetery charges, or to reimburse
any person not financially responsible for the deceased who has voluntarily
made expenditures for such costs.
(Source: P.A. 90-372, eff. 7-1-98.)
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(305 ILCS 5/3-9) (from Ch. 23, par. 3-9)
Sec. 3-9.
Claim against the estate of a deceased recipient.
On the death of a person who has been a recipient, the total amount paid
under this Article shall be filed and allowed as a claim against that person's
estate or as a claim against the estate of that person's surviving spouse.
No claim of the State, however, shall be enforced against any real
estate while it is occupied as a homestead by the recipient's surviving
spouse, or a relative of the recipient as defined by the rules and
regulations of the Illinois Department, if no claims by other creditors
have been filed against the estate, or, if such claims have been filed,
they remain dormant for failure of prosecution or failure of the claimant
to compel administration of the estate for the purpose of payment.
"Homestead", as used in this Section, means the dwelling house and
contiguous real estate occupied by a surviving spouse, or defined relative
of the recipient, regardless of the value of the property.
The transfer of money, personal property or other personal assets, or
any interest therein, by a present or former recipient into a joint tenancy
account in a bank or other institution or depository shall be prima facie
evidence of an intent to defeat the claim against his estate. The transfer
may be voided in an appropriate legal action, or the Illinois Department
may consider the recipient's interest in the joint tenancy account as an
asset of his estate for the purpose of the claim provided by this Section.
The Illinois Department may, by rule, defer or waive the enforcement of
its claim hereunder if the deceased recipient is survived by a dependent
spouse and minor child or children, or if rehabilitative training for
employment or other means of self-support for the surviving spouse or
children is feasible and the deferment or waiver of the claim would
facilitate achievement of self-support status and prevent or reduce the
likelihood of return to dependency upon public aid.
The estate claim herein provided is in addition to the lien claim
established in Section 3-10.
(Source: P.A. 88-85.)
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(305 ILCS 5/3-10)
Sec. 3-10. (Repealed).
(Source: P.A. 88-85. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.1)
Sec. 3-10.1. (Repealed).
(Source: P.A. 91-357, eff. 7-29-99. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.2)
Sec. 3-10.2. (Repealed).
(Source: P.A. 83-358. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.3)
Sec. 3-10.3. (Repealed).
(Source: P.A. 83-358. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.4)
Sec. 3-10.4. (Repealed).
(Source: P.A. 83-889. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.5)
Sec. 3-10.5. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.6)
Sec. 3-10.6. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.7)
Sec. 3-10.7. (Repealed).
(Source: P.A. 89-507, eff. 7-1-97. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.8)
Sec. 3-10.8. (Repealed).
(Source: P.A. 79-1365. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.9)
Sec. 3-10.9. (Repealed).
(Source: P.A. 89-507, eff. 7-1-97. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-10.10)
Sec. 3-10.10. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/3-11) (from Ch. 23, par. 3-11)
Sec. 3-11.
Fraudulent transfer of real property.
A transfer of any legal or equitable interest in real property, whether
vested, contingent, or inchoate, by a person who is or has been a
recipient, including any such transfers prior to application which would
have initially disqualified the person as provided in Section 3-1.3,
shall, under any of the following conditions, be deemed prima facie
fraudulent as to the Illinois Department.
(1.) Where the deed or assignment has not been recorded or registered by
the grantee, trustee, or assignee
(2.) When the deed or assignment, even though recorded or registered,
fails to state the consideration
(3.) When the consideration for the deed or assignment, even though
recorded or registered, is not paid
(4.) When the consideration for the deed or assignment, even though
recorded or registered, does not approximate the fair, cash market value.
The Attorney General, upon request of the Illinois Department, shall
file suit to rescind any such transfer or assignment of real property. Any
aid furnished under this Article shall be recoverable in any such proceeding
from such person or
from his estate.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/3-12) (from Ch. 23, par. 3-12)
Sec. 3-12.
(Repealed).
(Source: Repealed by P.A. 88-412.)
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(305 ILCS 5/3-13) (from Ch. 23, par. 3-13)
Sec. 3-13. Federal program - Declaration of responsibilities: It is the
position of this State that the Federal Government should meet its obligation
to provide financial aid to those aged, blind or disabled persons eligible
under Article III hereof so as to assure those persons a standard of living
compatible with health and well-being, including any supplementary aid program
provided to meet special or emergency needs, and it is the position of this
State that the Federal Government should meet its obligation to provide
continuing supplemental nutritional aid for such persons through the Federal
Food Stamp Program or through full reimbursement for expenditures made in lieu
of such Food Stamp Program.
(a) The Illinois Department may, from federal reimbursements received under
this Section, make disbursements to any attorney, or
advocate working under the supervision of an attorney, who represents a
recipient of assistance under Article VI of this Code in a program
administered by the Illinois Department, in an appeal
of any claim for federal Supplemental Security Income benefits before an
administrative law judge which is decided in favor of such
recipient. The amount of such disbursement shall be equal to 25% of the
maximum federal Supplemental Security Income grant payable to an individual
for a period of one year. No such disbursement shall be made unless a petition
and a copy of the favorable decision is submitted by such attorney or advocate
to the Illinois Department within 60 days of the date of such decision. The
disbursement shall be made within 30 days after the petition is received. The
Illinois Department shall promulgate rules and regulations necessary to
implement this subsection.
(b) The Illinois Department shall institute a State program to fully
supplement the federal Supplemental Security Income grants of all persons
in the aged, blind, or disabled categories who meet the eligibility and
need requirements of this Code. The amount or amounts of
such supplementary payments shall be established by the Director of the
Illinois Department in a manner consistent with the other provisions of
this Article III.
(c) The Illinois Department, the Comptroller and the Treasurer, are
authorized to disburse to the Federal Government amounts appropriated to
the Illinois Department for use in furnishing aid to persons eligible under
Article III of this Code, to receive reimbursements from the Federal
Government therefor, and to establish administrative procedures necessary
for the accomplishment of such a payment system.
(Source: P.A. 93-632, eff. 2-1-04.)
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(305 ILCS 5/3-14) (from Ch. 23, par. 3-14)
Sec. 3-14.
Authorization for Federal administration of supplement: The Illinois
Department is authorized to enter into an agreement with the Secretary of
Health, Education and Welfare for the Secretary to administer, as provided
in Section 1616 of the Social Security Act, any or all portions of a State
program to supplement grants.
(Source: P.A. 78-3rd S.S.-22.)
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(305 ILCS 5/3-15) (from Ch. 23, par. 3-15)
Sec. 3-15.
(Repealed).
(Source: P.A. 78-3rd S.S.-22. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/Art. IV heading) ARTICLE IV.
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES
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(305 ILCS 5/4-0.5)
Sec. 4-0.5.
Aid to Families with Dependent Children Program inoperative
after June 30, 1997. The Aid to Families with Dependent Children
(AFDC)
Program shall be inoperative after June 30, 1997.
Under the federal Temporary Assistance for Needy Children Program the
Illinois Department
shall develop an alternative program of mutual responsibility between the
Illinois Department and the client to allow the family to become
self-sufficient
or employed as quickly as possible through (i) the provision of
transitional assistance to families in the form of emergency one-time payments
to prevent job loss, temporary assistance while searching for or being trained
for work, or paternity establishment and child support enforcement or (ii) the
provision for continued work.
(Source: P.A. 89-6, eff. 3-6-95; 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-0.6)
Sec. 4-0.6.
Reference to AFDC considered a reference to TANF.
On and
after
the effective date of this amendatory Act of 1997, any reference to Aid to
Families with Dependent Children or AFDC shall be considered to be a reference
to Temporary Assistance for Needy Families or TANF.
(Source: P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-1) (from Ch. 23, par. 4-1)
Sec. 4-1. Eligibility requirements. Financial aid in meeting basic maintenance requirements for a livelihood
compatible with health and well-being shall be given under this Article to
or in behalf of families with dependent children who meet the eligibility
conditions of Sections 4-1.1 through 4-1.12. It shall be the policy of the Illinois Department to provide aid under this Article to all qualified persons who seek assistance and to conduct outreach efforts to educate the public about the program. The Department shall provide timely, accurate, and fair service to all applicants for assistance.
Persons who meet the eligibility criteria authorized under this Article shall
be treated equally, provided that nothing in this Article shall be construed to
create an entitlement to a particular grant or service level or to aid in
amounts not authorized under this Code, nor construed to limit the authority of
the General Assembly to change the eligibility requirements or provisions
respecting assistance amounts. The General Assembly recognizes that the need for aid will fluctuate with the economic situation in Illinois and that at times the number of people receiving aid under this Article will increase.
The Illinois Department shall advise every applicant for and recipient of
aid under this Article of (i) the requirement that all recipients move toward
self-sufficiency and (ii) the value and benefits of employment. As a condition
of eligibility for that aid, every person who applies for aid under this
Article on or after the effective date of this amendatory Act of 1995 shall
prepare and submit, as part of the application or subsequent redetermination,
a personal plan for achieving
employment and self-sufficiency.
The plan shall incorporate the individualized assessment and employability
plan set out in subsections (d), (f), and (g) of Section 9A-8. The plan may be
amended as the recipient's needs change. The assessment
process to develop the plan shall include questions that screen for domestic
violence issues and steps needed to address these issues may be part of the
plan. If the individual indicates that he or she is a victim of domestic
violence, he or she may also be referred to an available domestic violence
program.
Failure of the client to follow through on the
personal plan for employment and self-sufficiency may be a basis for sanction
under Section 4-21.
(Source: P.A. 96-866, eff. 7-1-10; 97-813, eff. 7-13-12.)
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(305 ILCS 5/4-1.1) (from Ch. 23, par. 4-1.1)
Sec. 4-1.1. Child age eligibility.
(a) Every assistance unit must include a child, except as provided in
subsections (b) and (c). The child or children must have already been born
and be under age 18, or, if age 18, must be a full-time student in a secondary
school or the equivalent level of vocational or technical training.
(b) Grants shall be provided for assistance units consisting exclusively
of a pregnant woman with no dependent child, and may include her husband if
living with her, if the pregnancy has been determined by medical diagnosis.
(c) Grants may be provided for assistance units consisting of only adults
if all the children living with those adults are children with disabilities and receive
Supplemental Security Income.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/4-1.2) (from Ch. 23, par. 4-1.2)
Sec. 4-1.2.
Living Arrangements - Parents - Relatives - Foster Care.
(a) The child or children must (1) be living with his or their father,
mother, grandfather, grandmother, brother, sister, stepfather,
stepmother, stepbrother, stepsister, uncle or aunt, or other relative
approved by the Illinois Department, in a place of residence maintained
by one or more of such relatives as his or their own home, or (2) have
been (a) removed from the home of the parents or other relatives by
judicial order under the Juvenile Court Act or the Juvenile Court Act of
1987, as amended, (b) placed under the
guardianship of the Department of Children and Family Services, and (c)
under such guardianship, placed in a foster family home, group home or
child care institution licensed pursuant to the "Child Care Act of 1969",
approved May 15, 1969, as amended, or approved by that Department
as meeting standards established for licensing under that Act, or (3) have
been relinquished in accordance with the Abandoned Newborn Infant Protection
Act. A child
so placed in foster care who was not receiving aid under this Article in
or for the month in which the court proceedings leading to that
placement were initiated may qualify only if he lived in the home of his
parents or other relatives at the time the proceedings were initiated,
or within 6 months prior to the month of initiation, and would have
received aid in and for that month if application had been made
therefor.
(b) The Illinois Department may, by rule, establish those persons who are
living together who must be included in the same assistance unit in order to
receive cash assistance under this Article and the income and assets of those
persons in an assistance unit which must be considered in determining
eligibility.
(c) The conditions of qualification herein specified shall not prejudice
aid granted under this Code for foster care prior to the effective date
of this 1969 Amendatory Act.
(Source: P.A. 92-408, eff. 8-17-01; 92-432, eff. 8-17-01.)
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(305 ILCS 5/4-1.2a) (from Ch. 23, par. 4-1.2a)
Sec. 4-1.2a.
Residents of public institutions.
Residents of municipal,
county, state or national institutions for persons with mental illness or
persons with a developmental disability or for the tuberculous, or residents of
a home or other institution maintained by such governmental bodies when not in
need of institutional care because of sickness, convalescence, infirmity, or
chronic illness, and inmates of penal or correctional institutions maintained
by such governmental bodies, may qualify for aid under this Article only after
they have ceased to be residents or inmates.
A person shall not be deemed a resident of a State institution for persons
with mental illness or persons with a developmental disability within the
meaning of this Section if he or she has been conditionally discharged by
the Department of Mental Health and Developmental Disabilities or the
Department of Human Services (acting as successor to the Department of Mental
Health and Developmental Disabilities) and is no longer residing in the
institution.
Recipients of benefits under this Article who become residents of such
institutions shall be permitted a period of up to 30 days in such institutions
without suspension or termination of eligibility. Benefits for which such
person is eligible shall be restored, effective on the date of discharge or
release, for persons who are residents of institutions. Within a reasonable
time after the discharge of a person who was a resident of an institution, the
Department shall redetermine the eligibility of such person.
The Department shall provide for procedures to expedite the determination of
incapacity
or ability to engage in employment of persons scheduled to be discharged from
facilities operated by the Department.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-1.2b) (from Ch. 23, par. 4-1.2b)
Sec. 4-1.2b.
(Repealed).
(Source: P.A. 87-1056. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-1.2c)
Sec. 4-1.2c.
Residence of child who is pregnant or a parent.
(a) Notwithstanding any other provision of this Code, no aid shall be paid
under this Article on behalf of a person under age 18 who has never married and
who has a child or is pregnant, unless that person resides with a parent,
legal guardian, or other adult relative or in a foster home, maternity home, or
other adult-supervised living arrangement.
(b) The Illinois Department may make an exception to the requirement of
subsection (a) in
any of the following circumstances:
(1) The person has no living parent or legal | ||
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(2) The Illinois Department determines that the | ||
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(3) The person has lived apart from the parent or | ||
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(c) (Blank).
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-1.3) (from Ch. 23, par. 4-1.3)
Sec. 4-1.3.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-1.4) (from Ch. 23, par. 4-1.4)
Sec. 4-1.4.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-1.5a) (from Ch. 23, par. 4-1.5a)
Sec. 4-1.5a.
Multiple convictions for violations of this Code.
To the
extent permitted under federal law, any person found guilty of a second
violation of Article VIIIA or under any law of the United States or of
any State which is substantially similar to Sections 8A-2 through 8A-5
shall be ineligible for financial aid under this Article, as provided
in Section 8A-8.
(Source: P.A. 85-286.)
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(305 ILCS 5/4-1.6) (from Ch. 23, par. 4-1.6)
Sec. 4-1.6. Need. Income available to the family as defined by the
Illinois Department by rule, or to the child
in the case of a child removed from his or her home, when added to
contributions in money, substance or services from other sources,
including income available from parents absent from the home or from a
stepparent, contributions made for the benefit of the parent or other
persons necessary to provide care and supervision to the child, and
contributions from legally responsible relatives, must be equal to or less than the grant amount established by Department regulation for such
a person. For purposes of eligibility for aid under this Article, the Department shall (a) disregard all earned income between the grant amount and 50% of the Federal Poverty Level and (b) disregard the value of all assets held by the family.
In considering income to be taken into account, consideration shall
be given to any expenses reasonably attributable to the earning of such
income. Three-fourths of the earned income of a household eligible for aid under this Article shall be disregarded when determining the level of assistance for which a household is eligible. All child support, whether it be current support, past support owed, or future support, that is collected on or after January 1, 2023 on behalf of a family shall be passed through to the family and disregarded in determining the amount of the assistance grant provided to the family under this Article. Any amount of child support that would be disregarded in determining the amount of the assistance grant shall be disregarded in determining eligibility for cash assistance provided under this Article. The Illinois Department may also permit all or any
portion of earned or other income to be set aside for the future
identifiable needs of a child. The Illinois Department
may provide by rule and regulation for the exemptions thus permitted or
required. The eligibility of any applicant for or recipient of public
aid under this Article is not affected by the payment of any grant under
the "Senior Citizens and Persons with Disabilities Property Tax Relief Act" or any distributions or items of income
described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The Illinois Department may, by rule, set forth criteria under which an
assistance unit is ineligible for cash assistance under this Article for a
specified number of months due to the receipt of a lump sum payment.
(Source: P.A. 102-1115, eff. 7-1-24.)
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(305 ILCS 5/4-1.6a)
Sec. 4-1.6a.
(Repealed).
(Source: P.A. 88-205. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-1.6b) Sec. 4-1.6b. Date for providing aid; employability assessment. (a) The Department shall provide financial aid no more than 45 days after the date of application. (b) During the first 45 days after the date of application, the applicant shall undergo a thorough employability assessment, in accordance with subsection (d) of Section 9A-8 of this Code, and shall prepare a personal plan for achieving employment and self-sufficiency in accordance with Section 4-1 of this Code. The requirement to engage in work-related activity may commence 30 days after the date of application. (c) Financial aid under this Article shall be authorized effective 30 days after the date of application, provided that the applicant is eligible on that date.
(Source: P.A. 96-866, eff. 7-1-10; 97-683, eff. 7-1-12.) |
(305 ILCS 5/4-1.7) (from Ch. 23, par. 4-1.7)
Sec. 4-1.7. Enforcement of parental child support obligation.
If the parent or parents of the child are failing to meet or are delinquent
in their legal obligation to support the child, the parent or other person
having custody of the child or the Department of Healthcare and Family Services may
request the law enforcement officer authorized or directed by law to so act
to file an action for the enforcement of such remedies as the law provides for
the fulfillment of the child support obligation.
If a parent has a judicial remedy against the other parent to compel child
support, or if, as the result of an action initiated by or in behalf of one
parent against the other, a child support order has been entered in respect to
which there is noncompliance or delinquency, or where the order so entered may
be changed upon petition to the court to provide additional support, the parent
or other person having custody of the child or the Department of Healthcare and Family Services may request the appropriate law enforcement officer to seek
enforcement of the remedy, or of the support order, or a change therein to
provide additional support. If the law enforcement officer is not authorized
by law to so act in these instances, the parent, or if so authorized by law the
other person having custody of the child, or the Department of Healthcare and Family Services may initiate an action to enforce these remedies.
A parent or other person having custody of the child must
comply with the requirements of Title IV of the federal Social
Security Act, and the regulations duly promulgated thereunder,
and any rules promulgated by the Illinois Department regarding enforcement
of the child support obligation. The
Department of Healthcare and Family Services
and the Department of Human Services may provide by rule for the
grant or continuation of aid to the person for a temporary period if he
or she accepts counseling or other services designed to increase his
or her motivation to seek enforcement of the child support obligation.
In addition to any other definition of failure or refusal to comply
with the requirements of Title IV of the federal Social Security Act, or
Illinois Department rule, in
the case of failure to attend court hearings, the parent or other person
can show cooperation by attending a court hearing or, if a court hearing
cannot be scheduled within 14 days following the court hearing that was
missed, by signing a statement that the parent or other person is now
willing to cooperate in the child support enforcement process and will
appear at any later scheduled court date. The parent or other person can
show cooperation by signing such a statement only once. If failure to
attend the court hearing or other failure to cooperate results in the case
being dismissed, such a statement may be signed after 2 months.
No denial or termination of medical assistance pursuant to this Section
shall commence during pregnancy of the parent or other person having custody
of the child or for 30 days after the termination of such pregnancy. The
termination of medical assistance may commence thereafter if the
Department of Healthcare and Family Services determines that the failure or refusal to comply
with this Section persists. Postponement of denial or termination of medical
assistance during pregnancy under this paragraph shall be effective only to
the extent it does not conflict with federal law or regulation.
Any evidence a parent or other person having custody of the child
gives in order to comply with the requirements of this Section shall not
render him or her liable to prosecution under Section 11-35 or 11-40 of the
Criminal Code of 2012.
When so requested, the Department of Healthcare and Family Services and the Department
of Human Services shall provide such services and assistance as the law
enforcement officer may require in connection with the filing of any action
hereunder.
The Department of Healthcare and Family Services and the Department of Human Services, as an expense of administration, may also provide applicants for and
recipients of aid with such services and assistance, including assumption
of the reasonable costs of prosecuting any action or proceeding, as may be
necessary to enable them to enforce the child support liability required
hereunder.
Nothing in this Section shall be construed as a requirement that an
applicant or recipient file an action for dissolution of marriage
against his or her spouse.
(Source: P.A. 100-201, eff. 8-18-17.)
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(305 ILCS 5/4-1.8) (from Ch. 23, par. 4-1.8)
Sec. 4-1.8.
Registration for and Acceptance of Employment.
Individuals who are unemployed, or employed for less than the
full working time for the occupation in which they are engaged, and
dependent members of the family age 16 or over who are not in regular
attendance in school as defined in Section 4-1.1, must comply with and
are subject to all the requirements of Article IXA.
(Source: P.A. 86-1184; 86-1381.)
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(305 ILCS 5/4-1.9) (from Ch. 23, par. 4-1.9)
Sec. 4-1.9. Participation in Educational and Vocational Training Programs.
(a) A parent or parents and a child age 16 or over not in regular
attendance
in school, as defined in Section 4-1.1 as that Section existed on August 26,
1969 (the effective date of Public Act 76-1047), for whom education and
training is suitable, must participate in the educational and vocational
training programs provided pursuant to Article IXA.
(b) A parent who is less than 20 years of age and who has not
received a
high school diploma or State of Illinois High School Diploma is required to be
enrolled in school or in an educational program that is expected to result in
the receipt of a high school diploma or State of Illinois High School Diploma,
except 18 and 19 year old parents may be assigned to work activities or
training if it is determined based on an individualized assessment that
secondary school is inappropriate.
(Source: P.A. 102-1100, eff. 1-1-23.)
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(305 ILCS 5/4-1.10) (from Ch. 23, par. 4-1.10)
Sec. 4-1.10.
Acceptance of Assignment to Job Search, Training and Work
Programs. An individual for whom the job search, training and work programs
established under Article IXA are applicable must accept
assignment to such programs.
The Illinois Department and the local governmental unit shall determine,
pursuant to rules and regulations, sanctions for persons failing to comply with
the requirements under this Section. However, no participant shall be
sanctioned for failure to satisfy job search requirements before a full
assessment of the participant's job readiness and employability, except that
for those persons subject to the job search program operated under this Section
an
assessment as defined by rule at the time of intake will meet the assessment
requirement. No participant shall be sanctioned for failure to satisfy the
minimum number of employer contacts if the participant made a good faith
effort.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-1.11) (from Ch. 23, par. 4-1.11)
Sec. 4-1.11.
(Repealed).
(Source: P.A. 88-554, eff. 7-26-94. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-1.12)
Sec. 4-1.12.
Five year limitation.
No assistance unit shall be eligible for a cash grant under this Article
if it includes an adult who has received cash assistance as an adult for 60
months, whether or not consecutive, after the effective date of this amendatory
Act of 1997. The Illinois Department may exempt individual assistance units
from the 60-month limitation or determine circumstances under which a month or
months would not count towards the 60-month limitation even though the
assistance unit did receive cash assistance under this Article.
(Source: P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-2) (from Ch. 23, par. 4-2)
Sec. 4-2. Amount of aid.
(a) The amount and nature of financial aid shall be determined in accordance
with the grant amounts, rules and regulations of the Illinois Department. Due
regard shall be given to the self-sufficiency requirements of the family and to
the income, money contributions and other support and resources available, from
whatever source. However, the amount and nature of any financial aid is not
affected by the payment of any grant under the "Senior Citizens and Persons with Disabilities Property Tax Relief Act" or any
distributions or items of income described under subparagraph (X) of paragraph
(2) of subsection (a) of Section 203 of the Illinois Income Tax Act. The aid
shall be sufficient, when added to all other income, money contributions and
support to provide the family with a grant in the amount established by
Department regulation.
(a-5) For the purposes of this subsection, TANF grant amounts shall consist of the following portions: (1) 75% shall be designated for the child or children | ||
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(2) 25% shall be designated for the adult member or | ||
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(b) The Illinois Department may conduct special projects, which may be
known as Grant Diversion Projects, under which recipients of financial aid
under this Article are placed in jobs and their grants are diverted to the
employer who in turn makes payments to the recipients in the form of salary
or other employment benefits. The Illinois Department shall by rule specify
the terms and conditions of such Grant Diversion Projects. Such projects
shall take into consideration and be coordinated with the programs
administered under the Illinois Emergency Employment Development Act.
(c) The amount and nature of the financial aid for a child requiring
care outside his own home shall be determined in accordance with the rules
and regulations of the Illinois Department, with due regard to the needs
and requirements of the child in the foster home or institution in which
he has been placed.
(d) If the Department establishes grants for family units consisting
exclusively of a pregnant woman with no dependent child or including her
husband if living with her, the grant amount for such a unit
shall be equal to the grant amount for an assistance unit consisting of one
adult, or 2 persons if the husband is included. Other than as herein
described, an unborn child shall not be counted
in determining the size of an assistance unit or for calculating grants.
Payments for basic maintenance requirements of a child or children
and the relative with whom the child or children are living shall be
prescribed, by rule, by the Illinois Department.
Grants under this Article shall not be supplemented by General
Assistance provided under Article VI.
(e) Grants shall be paid to the parent or other person with whom the
child or children are living, except for such amount as is paid in
behalf of the child or his parent or other relative to other persons or
agencies pursuant to this Code or the rules and regulations of the
Illinois Department.
(f) Subject to subsection (f-5), an assistance unit, receiving
financial
aid under this Article or
temporarily ineligible to receive aid under this Article under a penalty
imposed by the Illinois Department for failure to comply with the eligibility
requirements or that voluntarily requests termination of financial assistance
under this Article and becomes subsequently eligible for assistance within 9
months, shall not receive any increase in the amount of aid solely on account
of the birth of a child; except that an increase is not prohibited when the
birth is (i) of a child of a pregnant woman
who became eligible for aid under this Article during the pregnancy,
or (ii) of a child born within 10 months after the date of implementation of
this subsection, or (iii) of a child conceived after a family became
ineligible for assistance due to income or marriage and at least 3 months of
ineligibility expired before any reapplication for assistance. This subsection
does not, however, prevent a unit from receiving a general increase in the
amount of aid that is provided to all recipients of aid under this Article.
The Illinois Department is authorized to transfer funds, and shall use any
budgetary savings attributable to not increasing the grants due to the births
of additional children, to supplement existing funding for employment and
training services for recipients of aid under this Article IV. The Illinois
Department shall target, to the extent the supplemental funding allows,
employment and training services to the families who do not receive a grant
increase after the birth of a child. In addition, the Illinois Department
shall provide, to the extent the supplemental funding allows, such families
with up to 24 months of transitional child care pursuant to Illinois Department
rules. All remaining supplemental funds shall be used for employment and
training services or transitional child care support.
In making the transfers authorized by this subsection, the Illinois
Department shall first determine, pursuant to regulations adopted by the
Illinois Department for this purpose, the amount of savings attributable to
not increasing the grants due to the births of additional children. Transfers
may be made from General Revenue Fund appropriations for distributive purposes
authorized by Article IV of this Code only to General Revenue Fund
appropriations for employability development services including operating
and administrative costs and related distributive purposes under Article
IXA of this Code. The Director, with the approval of the Governor, shall
certify the amount and affected line item appropriations to the State
Comptroller.
Nothing in this subsection shall be construed to prohibit the Illinois
Department from using funds under this Article IV to provide
assistance in the form of vouchers
that may be used to pay for goods and services deemed by the Illinois
Department, by rule, as suitable for the care of the child such as diapers,
clothing, school supplies, and cribs.
(f-5) Subsection (f) shall not apply to affect the monthly assistance
amount of
any family as a result of the birth of a child on or after January 1, 2004.
As resources permit after January 1, 2004, the Department may
cease applying subsection (f) to limit assistance to families receiving
assistance under this Article on January 1, 2004, with respect to children
born prior to that date. In any event, subsection (f) shall be completely
inoperative on and after July 1, 2007.
(g) (Blank).
(h) Notwithstanding any other provision of this Code, the Illinois
Department is authorized to reduce payment levels used to determine cash grants
under this Article after December 31 of any fiscal year if the Illinois
Department determines that the caseload upon which the appropriations for the
current fiscal year are based have increased by more than 5% and the
appropriation is not sufficient to ensure that
cash benefits under this Article do not exceed the amounts appropriated for
those cash benefits. Reductions in payment levels may be accomplished by
emergency rule under Section 5-45 of the Illinois Administrative Procedure Act,
except that the limitation on the number of emergency rules that may be adopted
in a 24-month period shall not apply and the provisions of Sections 5-115 and
5-125 of the Illinois Administrative Procedure Act shall not apply.
Increases in payment levels shall be accomplished only in accordance with
Section 5-40 of the Illinois Administrative Procedure Act. Before any rule
to increase payment levels
promulgated under this Section shall become effective, a joint resolution
approving the rule must be adopted by a roll call vote by a majority of the
members elected to each chamber of the General Assembly.
(Source: P.A. 101-103, eff. 7-19-19.)
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(305 ILCS 5/4-3) (from Ch. 23, par. 4-3)
Sec. 4-3.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-3a) (from Ch. 23, par. 4-3a)
Sec. 4-3a.
No otherwise qualified child with a disability receiving special
education and related services under Article 14 of The School Code shall
solely by reason of his or her disability be excluded from the participation
in or be denied the benefits of or be subjected to discrimination under
any program or activity provided by the Department.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/4-4) (from Ch. 23, par. 4-4)
Sec. 4-4.
Entitlement to medical assistance.
Children and adults qualified for aid shall be entitled to receive,
under Article V, all necessary medical assistance.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/4-4.1)
Sec. 4-4.1. Immunizations.
(a) The Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) shall develop and
implement and that Department and the Department of Human Services shall
jointly continue by rule a program to ensure that children under 5 years of
age living
in assistance units that receive benefits under this Code are immunized. The
Illinois Department of Public Aid shall report to the Governor and the
General Assembly on
the progress of the program on April 1, 1994 and 1995.
(b) Nothing in this Section shall be construed to require immunization of
any child in contravention of the stated objections of a parent, guardian, or
relative with custody of a child that the administration of immunizing agents
conflicts with his or her religious tenets and practices.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/4-5) (from Ch. 23, par. 4-5)
Sec. 4-5.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-6) (from Ch. 23, par. 4-6)
Sec. 4-6.
(Repealed).
(Source: P.A. 85-195. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-7) (from Ch. 23, par. 4-7)
Sec. 4-7.
Home Visits, Interviews or Communications.
Each family receiving
aid shall be interviewed in person or communicated with in investigations
of applications for aid and at least once in each subsequent 12 month
period to ascertain continuing need for such aid and to provide the
child and his parents or relatives with such service and guidance as
will strengthen family life and aid them in utilizing to the maximum
their capacities for self-care, self-support, and responsible
citizenship. However, the Department shall determine those assistance
units where the possibility for public assistance fraud or abuse is
greatest, or where there is the possibility of frequent changes in need or
circumstances, or where any child in the home may be an abused or neglected
child as determined by the Department of Children and Family Services under
the Abused and Neglected Child Reporting Act, as now or hereafter amended,
and shall by rule provide for more frequent interviews of or
communications with those assistance units and for the implementation of
necessary remedies under Sections 4-8 and 4-9 for those assistance units.
Written reports of such interviews or communications and any related
remedies shall become a part of the record in every case.
(Source: P.A. 85-1209.)
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(305 ILCS 5/4-8) (from Ch. 23, par. 4-8)
Sec. 4-8. Mismanagement of assistance grant.
(a) If the County Department has
reason to believe that the money payment for basic maintenance is not being
used, or may not be used, in the best interests of the child and the family
and that there is present or potential damage to the standards of health
and well-being that the grant is intended to assure, the County Department
shall provide the parent or other relative with the counseling and guidance
services with respect to the use of the grant and the management of other
funds available to the family as may be required to assure use of the grant
in the best interests of the child and family. The Illinois Department
shall by rule
prescribe criteria which shall constitute evidence of grant mismanagement.
The criteria shall include but not be limited to the following:
(1) A determination that a child in the assistance | ||
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(2) A record establishing that the parent or relative | ||
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(3) A determination by an appropriate person, entity, | ||
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The Department shall at least consider non-payment of rent for two
consecutive months as evidence of grant mismanagement by a parent or
relative of a recipient who is responsible for making rental payments for
the housing or shelter of the child or family, unless the Department
determines that the non-payment is necessary for the protection of the
health and well-being of the recipient. The County Department shall advise
the parent or other relative grantee that continued mismanagement will
result in the application of one of the sanctions specified in this Section.
The Illinois Department shall consider irregular school attendance by
children of school age grades 1 through 8, as evidence of lack of
proper and necessary support or care. The Department may extend this
consideration to children in grades higher than 8.
The Illinois Department shall develop preventive programs in collaboration
with school and social service networks to encourage school
attendance of children receiving assistance under Article IV. To the extent
that Illinois Department and community resources are available, the programs
shall serve families whose children in grades 1 through 8 are not attending
school regularly, as defined by the school. The Department may extend these
programs to families whose children are in grades higher than 8. The
programs shall include referrals from the school to a social service network,
assessment and development of a service plan by one or more network
representatives, and the Illinois Department's encouragement of the family to
follow through with the service plan. Families that fail to follow the service
plan as determined by the service provider, shall be subject to the protective
payment provisions of this Section and Section 4-9 of this
Code.
Families for whom a protective payment plan has been in effect for at least
3 months and whose school children continue to regularly miss school shall be
subject to sanction under Section 4-21. The sanction shall continue until the
children demonstrate satisfactory attendance, as defined by the school. To the
extent necessary to implement this Section, the Illinois Department shall seek
appropriate waivers of federal requirements from the U.S. Department of Health
and Human Services.
(b) In areas of the State where clinically appropriate substance use disorder
treatment capacity is available, if the local office has reason to believe
that
a caretaker relative is experiencing a substance use disorder, the local office shall
refer the caretaker relative to a licensed treatment provider for assessment.
If the assessment indicates that the caretaker relative is experiencing
a substance use disorder, the local office shall require the caretaker relative to
comply with all treatment recommended by the assessment. If the caretaker
relative refuses without good cause, as determined by rules of the Illinois
Department, to submit to the assessment or treatment, the caretaker relative
shall be ineligible for assistance, and the local office shall take one or more
of the following actions:
(i) If there is another family member or friend who | ||
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(ii) If there is no family member or close friend to | ||
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(iii) The Department shall contact the individual who | ||
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(c) This subsection (c) applies to cases other than those described in
subsection (b). If the efforts to correct the mismanagement of the grant
have failed, the County Department, in accordance with the rules and
regulations of the Illinois Department, shall initiate one or more of the
following actions:
1. Provide for a protective payment to a substitute | ||
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2. Provide for issuance of all or part of the grant | ||
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3. File a petition under the Juvenile Court Act of | ||
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4. Institute a proceeding under the Juvenile Court | ||
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5. If the mismanagement of the grant, together with | ||
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(Source: P.A. 100-759, eff. 1-1-19.)
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(305 ILCS 5/4-9) (from Ch. 23, par. 4-9)
Sec. 4-9. Protective payment to substitute payee. If the parent or other
grantee relative persistently mismanages the grant to the detriment of the
child and the family but there is reason to believe that, with specialized
counseling and guidance services, the parent or relative may develop
ability to manage the funds properly, the County Department, in accordance
with the rules and regulations of the Illinois Department, may designate a
person who is interested in or concerned with the welfare of the child and
its family to receive the aid payment on behalf of the family. The County
Department may designate private welfare or social service agencies to
serve as substitute payees in appropriate cases.
The substitute payee shall serve without compensation and assume the
obligation of seeing that the aid payment is expended for the benefit of
the child and the family. He may spend the grant for the family, or
supervise the parent or other relative in the use of the grant, depending
upon the circumstances in each case, and shall make monthly reports to
the County Department as the County Department and the Illinois Department
may require.
The County Department shall terminate the protective payment when it is
no longer necessary to assure that the grant is being used for the welfare
of the child and family, or when the parent or other relative is no
longer receiving and no longer requires treatment for substance use disorders, mental health services, or other special care or treatment.
A substitute payee may be removed, in accordance with the rules and
regulations of the Illinois Department, for unsatisfactory service. The
removal may be effected without hearing. The decision shall not be
appealable to the Illinois Department nor shall it be reviewable in the courts.
The County Department shall conduct periodic reviews as may be
required by the Illinois Department to determine whether there is a
continuing need for a protective payment. If it appears that the need for
the payment is likely to continue beyond a reasonable period,
the County Department shall take one of the other actions set out in
Section 4-8.
The parent or other relative shall be advised, in advance of a
determination to make a protective payment, that he may appeal the decision
to the Illinois Department under the provisions of Section 11-8 of Article
XI.
(Source: P.A. 100-759, eff. 1-1-19.)
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(305 ILCS 5/4-10) (from Ch. 23, par. 4-10)
Sec. 4-10.
Funeral and burial.
If the estate of a deceased recipient is insufficient to pay for funeral
and burial expenses, and if no other resources, including assistance from
legally responsible relatives, are available for such purposes, there shall
be paid, in accordance with the standards, rules and regulations of the
Illinois Department, such reasonable amounts as may be necessary to meet
costs of the funeral, burial space, and cemetery charges or to reimburse
any person not financially responsible for the deceased who has voluntarily
made expenditures for such costs.
(Source: P.A. 90-372, eff. 7-1-98.)
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(305 ILCS 5/4-11) (from Ch. 23, par. 4-11)
Sec. 4-11.
Charge
of child.
Public officials, agents, or representatives, in carrying out any of the
provisions of this Article, shall not take charge of any child over the
objection of either of the child's parents, or of the persons standing in
loco parentis to the child, except pursuant to court order.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/4-12) (from Ch. 23, par. 4-12)
Sec. 4-12. Crisis assistance. Where a family has been (1) rendered homeless
or threatened with homelessness by fire, flood, other natural
disaster, eviction or court order to vacate the premises for reasons
other than nonpayment of rent, or where a family has become
homeless because they have left their residence due to domestic or sexual violence; (1.5) deprived of the household's income as a result of domestic or sexual violence; (2) deprived of
essential items of furniture or essential clothing by fire or flood or
other natural disaster; (3) deprived of food as a result of actions other
than loss or theft of cash and where the deprivation cannot be promptly
alleviated through the federal food stamp program;
(4) as a result of a documented theft or documented loss of cash, deprived of
food or essential clothing or deprived of shelter or
immediately threatened with deprivation of shelter as evidenced by a court
order requiring immediate eviction due to nonpayment of rent; or (5) rendered the victim of such other
hardships as the Illinois Department shall by rule define, the Illinois
Department may provide assistance to alleviate such
needs. The
Illinois Department shall verify need and determine eligibility for
crisis
assistance for families already receiving grants from the Illinois
Department within 5 working days following application for such assistance
and shall determine eligibility for all other families and afford such
assistance for families found eligible within such
time limits as the Illinois Department shall by rule provide.
The Illinois Department may, by rule, limit crisis assistance
to an
eligible family to once
in any 12
consecutive months. This limitation may be made for some or all items of
crisis assistance.
The Illinois Department by regulation shall specify the
criteria for determining eligibility and the amount and nature of
assistance to be provided. Where deprivation of
shelter exists or is threatened, the
Illinois Department may provide reasonable moving expenses, short term
rental costs, including one month's rent and a security deposit where such
expenses are needed for relocation, and, where the Department determines
appropriate, provide assistance to prevent an imminent eviction or
foreclosure. These amounts may be described in established amounts or
maximums. The Illinois Department may also describe, for each form of
assistance authorized, the method by which the assistance shall be
delivered, including but not limited to warrants or disbursing orders.
Annual expenditures under this
Section shall not exceed $2,000,000. The Illinois
Department shall review
such expenditures quarterly and shall, if necessary, reduce the amounts or
nature of assistance authorized in order to assure that the limit is not
exceeded.
(Source: P.A. 96-866, eff. 7-1-10.)
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(305 ILCS 5/4-13) (from Ch. 23, par. 4-13)
Sec. 4-13.
(Repealed).
(Source: P.A. 83-1273. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-14) (from Ch. 23, par. 4-14)
Sec. 4-14.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
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(305 ILCS 5/4-15) (from Ch. 23, par. 4-15)
Sec. 4-15.
(Repealed).
(Source: Repealed by P.A. 89-131, eff. 7-14-95.)
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(305 ILCS 5/4-16) (from Ch. 23, par. 4-16)
Sec. 4-16.
(Repealed).
(Source: P.A. 88-412. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/4-17)
Sec. 4-17. (Repealed).
(Source: P.A. 92-111, eff. 1-1-02. Repealed by P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/4-18)
Sec. 4-18.
(Repealed).
(Source: P.A. 89-626, eff. 8-9-96. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-19)
Sec. 4-19.
(Repealed).
(Source: P.A. 90-538, eff. 12-1-97. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/4-21)
Sec. 4-21. Sanctions.
(a) The Illinois Department shall, by rule, establish a system of sanctions
for persons who fail to cooperate, without good cause, with employment and
training programs or other programs under this Article or Article IXA or who
fail to cooperate
with child support programs under this Article, Article X, or Title IV of the
federal Social Security Act. The sanctions may be time limited or
continue until the person cooperates in the program. The sanctions may be
progressive in that a second, third, or further sanction may be progressively
more severe or last longer.
(a-1) The Illinois Department shall, by rule, impose a 30% reduction of the portion of the grant amount designated for the adult member or members of the assistance unit when an adult member is found to be in noncompliance without good cause. (a-2) No sanction shall reduce the portion of the grant amount that is designated for the child or children of the assistance unit. (a-3) The full grant amount must be restored on the first day of the month following a determination that the adult member or members of the assistance unit are in compliance with program requirements and are otherwise eligible for assistance. (b) The Illinois Department shall, by rule, define what constitutes failure
to cooperate and what constitutes good cause which would excuse that failure.
(Source: P.A. 101-103, eff. 7-19-19.)
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(305 ILCS 5/4-22)
Sec. 4-22. Domestic and sexual violence.
(a) The assessment process to develop the personal plan for achieving
self-sufficiency shall include questions that screen for domestic and sexual violence
issues. If the individual indicates that he or she is the victim of domestic or sexual
violence and indicates a need to address domestic or sexual violence issues in order to
reach self-sufficiency, the plan shall take this factor into account in
determining the work, education, and training activities suitable to the client
for achieving self-sufficiency. In addition, in such a case, specific steps
needed to directly address the domestic or sexual violence issues may also be made part
of the plan, including referral to an available domestic or sexual violence program. The Department shall conduct an individualized assessment and grant waivers of program requirements and other required activities for victims of domestic violence to the fullest extent allowed by 42 U.S.C. 602(a)(7)(A), and shall apply the same laws, regulations, and policies to victims of sexual violence. The duration of such waivers shall be initially determined and subsequently redetermined on a case-by-case basis. There shall be no limitation on the total number of months for which waivers under this Section may be granted, but continuing eligibility for a waiver shall be redetermined no less often than every 6 months.
(b) The Illinois Department shall develop and monitor compliance procedures
for its employees, contractors, and subcontractors to ensure that any
information pertaining to any client who claims to be a past or present victim
of domestic violence or an individual at risk of further domestic violence,
whether provided by the victim or by a third party, will remain
confidential.
(c) The Illinois Department shall develop and implement a domestic
violence
training
curriculum for Illinois Department employees who serve applicants for and
recipients of aid
under this Article. The curriculum shall be designed to better equip those
employees to identify
and serve domestic violence victims.
The Illinois Department may enter into a contract for the development of the
curriculum with one or more organizations providing
services to domestic violence victims. The Illinois Department shall adopt
rules necessary to implement this subsection.
(Source: P.A. 96-866, eff. 7-1-10.)
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(305 ILCS 5/4-23)
Sec. 4-23. Civil rights impact statement. (a) The Department of Human Services
must
submit to the Governor and the General Assembly
on January 1 of each even-numbered year a written report
that details the disparate impact of various
provisions of the TANF program on people of different racial or ethnic
groups
who
identify themselves in an application for benefits as any of the following: (1) American Indian or Alaska Native (a person having | ||
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(2) Asian (a person having origins in any of the | ||
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(3) Black or African American (a person having | ||
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(4) Hispanic or Latino (a person of Cuban, Mexican, | ||
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(5) Native Hawaiian or Other Pacific Islander (a | ||
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(6) White (a person having origins in any of the | ||
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(b) The report must
at least compare the
number of
persons in each group:
(1) who are receiving TANF assistance;
(2) whose 60-month lifetime limit on receiving | ||
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(3) who have left TANF due to earned income;
(4) who have left TANF due to non-compliance with | ||
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(5) whose TANF grants have been reduced by sanctions | ||
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(6) who have returned to TANF 6 months after leaving | ||
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(7) who have returned to TANF 12 months after leaving | ||
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(8) who have one or more children excluded from | ||
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(9) who have been granted an exemption from work | ||
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(10) who are participating in post-secondary | ||
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(Source: P.A. 102-465, eff. 1-1-22.) |
(305 ILCS 5/Art. V heading) ARTICLE V.
MEDICAL ASSISTANCE
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(305 ILCS 5/5-1) (from Ch. 23, par. 5-1)
Sec. 5-1. Declaration of purpose. It is the purpose of this Article to
provide a program of essential
medical care and rehabilitative services for persons receiving basic
maintenance grants under this Code and for other persons who are unable,
because of inadequate resources, to meet their essential medical needs.
Preservation of health, alleviation of sickness, and correction of
disabling conditions for persons requiring maintenance support are
essential if they are to have an opportunity to become self-supporting or
to attain a greater capacity for self-care. For persons who are medically
indigent but otherwise able to provide themselves with a livelihood, it is
of special importance to maintain their incentives for continued
independence and preserve their limited resources for ordinary maintenance
needs to prevent their total or substantial dependency.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5-1.1) (from Ch. 23, par. 5-1.1)
Sec. 5-1.1. Definitions. The terms defined in this Section
shall have the meanings ascribed to them, except when the
context otherwise requires.
(a) "Nursing facility" means a facility, licensed by the Department of Public Health under the Nursing Home Care Act, that provides nursing facility services within the meaning of Title XIX of
the federal Social Security Act.
(b) "Intermediate care facility for persons with developmental disabilities" or "ICF/DD" means a facility, licensed by the Department of Public Health under the ID/DD Community Care Act, that is an intermediate care facility for the mentally retarded within the meaning of Title XIX
of the federal Social Security Act.
(c) "Standard services" means those services required for
the care of all patients in the facility and shall, as a
minimum, include the following: (1) administration; (2)
dietary (standard); (3) housekeeping; (4) laundry and linen;
(5) maintenance of property and equipment, including utilities;
(6) medical records; (7) training of employees; (8) utilization
review; (9) activities services; (10) social services; (11)
disability services; and all other similar services required
by either the laws of the State of Illinois or one of its
political subdivisions or municipalities or by Title XIX of
the Social Security Act.
(d) "Patient services" means those which vary with the
number of personnel; professional and para-professional
skills of the personnel; specialized equipment, and reflect
the intensity of the medical and psycho-social needs of the
patients. Patient services shall as a minimum include:
(1) physical services; (2) nursing services, including
restorative nursing; (3) medical direction and patient care
planning; (4) health related supportive and habilitative
services and all similar services required by either the
laws of the State of Illinois or one of its political
subdivisions or municipalities or by Title XIX of the
Social Security Act.
(e) "Ancillary services" means those services which
require a specific physician's order and defined as under
the medical assistance program as not being routine in
nature for skilled nursing facilities and ICF/DDs.
Such services generally must be authorized prior to delivery
and payment as provided for under the rules of the Department
of Healthcare and Family Services.
(f) "Capital" means the investment in a facility's assets
for both debt and non-debt funds. Non-debt capital is the
difference between an adjusted replacement value of the assets
and the actual amount of debt capital.
(g) "Profit" means the amount which shall accrue to a
facility as a result of its revenues exceeding its expenses
as determined in accordance with generally accepted accounting
principles.
(h) "Non-institutional services" means those services provided under
paragraph (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and those services provided under Section 4.02 of the Illinois Act on the Aging.
(i) (Blank).
(j) "Institutionalized person" means an individual who is an inpatient
in an ICF/DD or nursing facility, or who is an inpatient in
a medical
institution receiving a level of care equivalent to that of an ICF/DD or nursing facility, or who is receiving services under
Section 1915(c) of the Social Security Act.
(k) "Institutionalized spouse" means an institutionalized person who is
expected to receive services at the same level of care for at least 30 days
and is married to a spouse who is not an institutionalized person.
(l) "Community spouse" is the spouse of an institutionalized spouse.
(m) "Health Benefits Service Package" means, subject to federal approval, benefits covered by the medical assistance program as determined by the Department by rule for individuals eligible for medical assistance under paragraph 18 of Section 5-2 of this Code. (n) "Federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services. These guidelines set poverty levels by family size. (Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)
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(305 ILCS 5/5-1.2)
Sec. 5-1.2. Recipient eligibility verification.
(a) The Illinois Department shall initiate a statewide system by which
providers and sites of medical care can electronically verify recipient
eligibility for aid under this Article.
High-volume providers and sites of medical care, as defined by the Illinois
Department by rule, shall be required to participate in the eligibility
verification system.
Every non-high-volume provider and site of medical
care shall be afforded the opportunity to participate in the eligibility
verification system.
The Illinois Department shall provide by rule for
implementation of the system, which may be accomplished in phases over time and
by geographic region, recipient classification, and provider type.
The system shall initially be implemented in, but not limited to, the
following zip codes in Cook County: 60601, 60602, 60603, 60604, 60605, 60606,
60607, 60608, 60609, 60612, and 60616. The system shall be implemented within
6
months after approval by the federal government. The Illinois Department shall
report to the General Assembly by December 31, 1994 on the status of the
Illinois Department's application to the federal government for approval of
this system.
The recipient eligibility verification system may be coordinated with the
Electronic Benefits Transfer system established by Section 11-3.1 of this Code
and compatible with any of the methods for the delivery of medical care and
services authorized by this Article.
The system shall make available to providers the history of claims for
medical services submitted to the Illinois Department for those services
provided to the recipient. The Illinois Department shall develop safeguards to
protect each recipient's health information from misuse or unauthorized
disclosure.
(b) The Illinois Department shall conduct a demonstration project in at
least 2 geographic locations for the purpose of assessing the effectiveness of
a recipient photo identification card in reducing abuses in the provision of
services under this Article. In order to receive medical care, recipients
included in this demonstration project must present a Medicaid card and photo
identification card. The Illinois Department shall apply for any federal
waivers or approvals necessary to conduct this demonstration project. The
demonstration project shall become operational (i) 12 months after the
effective
date of this amendatory Act of 1994 or (ii) after the Illinois Department's
receipt
of all necessary federal waivers and approvals, whichever occurs later, and
shall operate for 12 months.
(c) Effective October 1, 2007, all changes in status of Medicaid recipients
residing in Illinois nursing facilities after initial eligibility for
Medicaid has been established shall be reported to the Department, using an
Internet-based electronic data interchange system, by the nursing facilities,
except for those changes made by personnel of the Department. Changes reported
using the Internet-based electronic data interchange system shall be deemed
valid and shall be used as the basis for future Medicaid payments unless
Department approval of the transaction is required, or until such time as
any review or audit conducted by the State establishes that the
information is incorrect.
(Source: P.A. 95-458, eff. 8-27-07.)
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(305 ILCS 5/5-1.3) Sec. 5-1.3. Payer of last resort. To the extent permissible under federal law, the State may pay for medical services only after payment from all other sources of payment have been exhausted, or after the Department has determined that pursuit of such payment is economically unfeasible. Applicants for, and recipients of, medical assistance under this Code shall disclose to the State all insurance coverage they have. To the extent permissible under federal law, the State shall require vendors of medical services to bill third-party payers for services that may be covered by those third-party payers prior to submission of a request for payment to the State. The Department shall, to the extent permissible under federal law, reject a request for payment of a medical service that should first have been submitted to a third-party payer.
(Source: P.A. 96-1501, eff. 1-25-11.) |
(305 ILCS 5/5-1.4) Sec. 5-1.4. Moratorium on eligibility expansions. Beginning on January 25, 2011 (the effective date of Public Act 96-1501), there shall be a 4-year moratorium on the expansion of eligibility through increasing financial eligibility standards, or through increasing income disregards, or through the creation of new programs which would add new categories of eligible individuals under the medical assistance program in addition to those categories covered on January 1, 2011 or above the level of any subsequent reduction in eligibility. This moratorium shall not apply to expansions required as a federal condition of State participation in the medical assistance program or to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds. If the State of Illinois finds that the State has borne a cost related to such an expansion, the unit of local government shall reimburse the State. All federal funds associated with an expansion funded by a unit of local government shall be returned to the local government entity funding the expansion, pursuant to an intergovernmental agreement between the Department of Healthcare and Family Services and the local government entity. Within 10 calendar days of the effective date of this amendatory Act of the 97th General Assembly, the Department of Healthcare and Family Services shall formally advise the Centers for Medicare and Medicaid Services of the passage of this amendatory Act of the 97th General Assembly. The State is prohibited from submitting additional waiver requests that expand or allow for an increase in the classes of persons eligible for medical assistance under this Article to the federal government for its consideration beginning on the 20th calendar day following the effective date of this amendatory Act of the 97th General Assembly until January 25, 2015. This moratorium shall not apply to those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and 42 U.S.C. 1396a(a)(10)(A)(i)(IX).
(Source: P.A. 97-687, eff. 6-14-12; 98-104, eff. 7-22-13.) |
(305 ILCS 5/5-1.5) Sec. 5-1.5. COVID-19 public health emergency. Notwithstanding any other provision of Articles V, XI, and XII of this Code, the Department may take necessary actions to address the COVID-19 public health emergency to the extent such actions are required, approved, or authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services. Such actions may continue throughout the public health emergency and for up to 12 months after the period ends, and may include, but are not limited to: accepting an applicant's or recipient's attestation of income, incurred medical expenses, residency, and insured status when electronic verification is not available; eliminating resource tests for some eligibility determinations; suspending redeterminations; suspending changes that would adversely affect an applicant's or recipient's eligibility; phone or verbal approval by an applicant to submit an application in lieu of applicant signature; allowing adult presumptive eligibility; allowing presumptive eligibility for children, pregnant women, and adults as often as twice per calendar year; paying for additional services delivered by telehealth; and suspending premium and co-payment requirements. The Department's authority under this Section shall extend to encompass, incorporate, or effectuate the terms, items, conditions, and other provisions approved, authorized, or required by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, and shall not extend beyond the time of the COVID-19 public health emergency and up to 12 months after the period expires.
Any individual determined eligible for medical assistance under this Code as of or during the COVID-19 public health emergency may be treated as eligible for such medical assistance benefits during the COVID-19 public health emergency, and up to 12 months after the period expires, regardless of whether federally required or whether the individual's eligibility may be State or federally funded, unless the individual requests a voluntary termination of eligibility or ceases to be a resident. This paragraph shall not restrict any determination of medical need or appropriateness for any particular service and shall not require continued coverage of any particular service that may be no longer necessary, appropriate, or otherwise authorized for an individual. Nothing shall prevent the Department from determining and properly establishing an individual's eligibility under a different category of eligibility. (Source: P.A. 101-649, eff. 7-7-20; 102-43, eff. 7-6-21.) |
(305 ILCS 5/5-1.6) Sec. 5-1.6. Continuous eligibility; ex parte redeterminations. (a) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers necessary to make changes to the medical assistance program. The Department shall apply for federal approval to implement 12 months of continuous eligibility for adults participating in the medical assistance program. The Department shall secure federal financial participation in accordance with this Section for expenditures made by the Department in State Fiscal Year 2023 and every State fiscal year thereafter. (b) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers or approvals necessary to make changes to the medical assistance redetermination process for people without any income at the time of redetermination. These changes shall seek to allow all people without income to be considered for ex parte redetermination. If there is no non-income related disqualifying information for medical assistance recipients without any income, then a person without any income shall be redetermined ex parte. Within 60 days after receiving federal approval or guidance, the Department of Healthcare and Family Services and the Department of Human Services shall make necessary technical and rule changes to implement changes to the redetermination process. The percentage of medical assistance recipients whose eligibility is renewed through the ex parte redetermination process shall be reported monthly by the Department of Healthcare and Family Services on its website in accordance with subsection (d) of Section 11-5.1 of this Code as well as shared in all Medicaid Advisory Committee meetings and Medicaid Advisory Committee Public Education Subcommittee meetings.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of persons eligible. Medical assistance under this
Article shall be available to any of the following classes of persons in
respect to whom a plan for coverage has been submitted to the Governor
by the Illinois Department and approved by him. If changes made in this Section 5-2 require federal approval, they shall not take effect until such approval has been received:
1. Recipients of basic maintenance grants under | ||
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2. Beginning January 1, 2014, persons otherwise | ||
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(a) All persons otherwise eligible for basic | ||
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(i) their income, as determined by the | ||
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(ii) their income, after the deduction of | ||
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(b) (Blank).
3. (Blank).
4. Persons not eligible under any of the preceding | ||
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5.(a) Beginning January 1, 2020, individuals during | ||
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(b) The plan for coverage shall provide ambulatory | ||
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(c) The Illinois Department may conduct a | ||
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6. (a) Subject to federal approval, children younger | ||
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(b) Children and youth who are under temporary | ||
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7. (Blank).
8. As required under federal law, persons who are | ||
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(a) extend the medical assistance coverage to the | ||
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(b) offer persons who have initially received 6 | ||
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(i) such coverage shall be pursuant to | ||
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(ii) such coverage shall include all services | ||
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(iii) no premium shall be charged for such | ||
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(iv) such coverage shall be suspended in the | ||
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9. Persons with acquired immunodeficiency syndrome | ||
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10. Participants in the long-term care insurance | ||
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11. Persons with disabilities who are employed and | ||
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(a) set the income eligibility standard at not | ||
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(b) exempt retirement accounts that the person | ||
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(c) allow non-exempt assets up to $25,000 as to | ||
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(d) continue to apply subparagraphs (b) and (c) | ||
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12. Subject to federal approval, persons who are | ||
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(1) persons who have been screened for breast or | ||
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(2) persons whose screenings under the above | ||
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"Medical assistance" under this paragraph 12 shall be | ||
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In addition to the persons who are eligible for | ||
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13. Subject to appropriation and to federal approval, | ||
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14. Subject to the availability of funds for this | ||
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15. Family Care Eligibility. (a) On and after July 1, 2012, a parent or other | ||
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(b) Eligibility shall be reviewed annually. (c) (Blank). (d) (Blank). (e) (Blank). (f) (Blank). (g) (Blank). (h) (Blank). (i) Following termination of an individual's | ||
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16. Subject to appropriation, uninsured persons who | ||
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17. Persons who, pursuant to a waiver approved by | ||
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(a) Limit the geographic areas in which | ||
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(b) Determine the scope, quantity, duration, and | ||
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(c) Restrict the persons' freedom in | ||
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18. Beginning January 1, 2014, persons aged 19 or | ||
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19. Beginning January 1, 2014, as required under 42 | ||
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20. Beginning January 1, 2018, persons who are | ||
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21. Persons who are not otherwise eligible for | ||
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In implementing the provisions of Public Act 96-20, the Department is authorized to adopt only those rules necessary, including emergency rules. Nothing in Public Act 96-20 permits the Department to adopt rules or issue a decision that expands eligibility for the FamilyCare Program to a person whose income exceeds 185% of the Federal Poverty Level as determined from time to time by the U.S. Department of Health and Human Services, unless the Department is provided with express statutory authority.
The eligibility of any such person for medical assistance under this
Article is not affected by the payment of any grant under the Senior
Citizens and Persons with Disabilities Property Tax Relief Act or any distributions or items of income described under
subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act. The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for medical assistance,
which shall at a minimum equal the amounts to be disregarded under the
Federal Supplemental Security Income Program. The amount of assets of a
single person to be disregarded
shall not be less than $2,000, and the amount of assets of a married couple
to be disregarded shall not be less than $3,000.
To the extent permitted under federal law, any person found guilty of a
second violation of Article VIIIA
shall be ineligible for medical assistance under this Article, as provided
in Section 8A-8.
The eligibility of any person for medical assistance under this Article
shall not be affected by the receipt by the person of donations or benefits
from fundraisers held for the person in cases of serious illness,
as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement
of the donations or benefits.
Notwithstanding any other provision of this Code, if the United States Supreme Court holds Title II, Subtitle A, Section 2001(a) of Public Law 111-148 to be unconstitutional, or if a holding of Public Law 111-148 makes Medicaid eligibility allowed under Section 2001(a) inoperable, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible. Notwithstanding any other provision of this Code, if an Act of Congress that becomes a Public Law eliminates Section 2001(a) of Public Law 111-148, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible. Effective October 1, 2013, the determination of eligibility of persons who qualify under paragraphs 5, 6, 8, 15, 17, and 18 of this Section shall comply with the requirements of 42 U.S.C. 1396a(e)(14) and applicable federal regulations. The Department of Healthcare and Family Services, the Department of Human Services, and the Illinois health insurance marketplace shall work cooperatively to assist persons who would otherwise lose health benefits as a result of changes made under Public Act 98-104 to transition to other health insurance coverage. (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22.)
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(305 ILCS 5/5-2.06a) Sec. 5-2.06a. Medically fragile children; reimbursement for legally responsible family caregivers. By January 1, 2025, the Department of Healthcare and Family Services shall apply for a Home and Community-Based Services State Plan amendment and any federal waiver necessary to reimburse legally responsible family caregivers as providers of personal care or home health aide services under the Illinois Title XIX State Plan Home and Community-Based Services benefit and the home and community-based services waiver program authorized under Section 1915(c) of the Social Security Act for persons who are medically fragile and technology dependent. To be eligible for reimbursement under this Section, a legally responsible family caregiver must be a certified nursing assistant or certified nurse aide and must provide services to a medically fragile relative who is receiving in-home shift nursing services coordinated by the University of Illinois at Chicago, Division of Specialized Care for Children. Upon federal approval of the State Plan amendment and waiver, the Department shall promulgate rules that define who qualifies for reimbursement as a legally responsible family caregiver, specify which personal care and home health aide services are eligible for reimbursement if the provider is a legally responsible family caregiver, establish oversight policies to ensure legally responsible family caregivers meet and comply with licensing and program requirements, and adopt any other policies or procedures necessary to implement this Section.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-2a) Sec. 5-2a. Medicaid State Plan; eligibility determination status. The Department shall conduct an analysis and deliver a report to the General Assembly by January 1, 2012 to evaluate the feasibility of changing Illinois' Medicaid State Plan from 209(b) status to the federal 1634 eligibility determination status for applicable individuals as provided in the Social Security Act. The report shall include a review of the current standard used by the Department, anticipated fiscal implications of converting to 1634 status, anticipated changes in caseloads resulting from a change to 1634 status, and any additional information deemed relevant by the Department to evaluate the feasibility of converting to 1634 status.
(Source: P.A. 97-173, eff. 7-22-11.) |
(305 ILCS 5/5-2b) Sec. 5-2b. Medically fragile and technology dependent children eligibility and program; provider reimbursement rates. (a) Notwithstanding any other provision of law except as provided in Section 5-30a, on and after September 1, 2012, subject to federal approval, medical assistance under this Article shall be available to children who qualify as persons with a disability, as defined under the federal Supplemental Security Income program and who are medically fragile and technology dependent. The program shall allow eligible children to receive the medical assistance provided under this Article in the community and must maximize, to the fullest extent permissible under federal law, federal reimbursement and family cost-sharing, including co-pays, premiums, or any other family contributions, except that the Department shall be permitted to incentivize the utilization of selected services through the use of cost-sharing adjustments. The Department shall establish the policies, procedures, standards, services, and criteria for this program by rule. (b) Notwithstanding any other provision of this Code, subject to federal approval, on and after January 1, 2024, the reimbursement rates for nursing paid through Nursing and Personal Care Services for non-waiver customers and to providers of private duty nursing services for children eligible for medical assistance under this Section shall be 20% higher than the reimbursement rates in effect for nursing services on December 31, 2023. (c) Notwithstanding any other provision of this Code, subject to federal approval, on and after January 1, 2025, the reimbursement rates for nursing paid through Nursing and Personal Care Services for non-waiver customers and to providers of private duty nursing services for children eligible for medical assistance under this Section shall be 7% higher than the reimbursement rates in effect for nursing services on December 31, 2024. (Source: P.A. 103-102, eff. 1-1-24; 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-2.01) Sec. 5-2.01. Medicaid accountability through transparency program. (a) Internet-based transparency program. The Director of the Department of Healthcare and Family Services shall be authorized to implement a program under which the Director shall make available through the Department's public Internet website information on medical claims reimbursed under the State's medical assistance program insofar as such information has been de-identified in accordance with regulations promulgated pursuant to the Illinois Health Insurance Portability and Accountability Act. In implementing the program, the Director shall ensure the following: (1) The information made so available shall be in a | ||
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(2) The information made so available shall be as | ||
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(3) The information made so available shall be | ||
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(4) The Director periodically solicits comments from | ||
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(b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate. (c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a). The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program.
(Source: P.A. 96-941, eff. 6-25-10.) |
(305 ILCS 5/5-2.03) Sec. 5-2.03. Presumptive eligibility. Beginning on the effective date of this amendatory Act of the 96th General Assembly and except where federal law requires presumptive eligibility, no adult may be presumed eligible for medical assistance under this Code and the Department may not cover any service rendered to an adult unless the adult has completed an application for benefits, all required verifications have been received, and the Department or its designee has found the adult eligible for the date on which that service was provided. Nothing in this Section shall apply to pregnant women or to persons enrolled under the medical assistance program due to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds.
(Source: P.A. 96-1501, eff. 1-25-11; 97-687, eff. 6-14-12.) |
(305 ILCS 5/5-2.05)
Sec. 5-2.05. Children with disabilities.
(a) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services,
may offer, to children with developmental
disabilities or children with severe mental illness or severe emotional disorders who
otherwise would not qualify for medical assistance under this Article due to
family income, home-based and community-based services instead of institutional
placement, as allowed under paragraph 7 of Section 5-2.
(b) The Department of Healthcare and Family Services, in conjunction with the Department of
Human Services and the Division of Specialized Care for Children, University of
Illinois-Chicago, shall submit a bi-annual
report to the Governor and the General Assembly no
later than January 1 of every even-numbered year, beginning in 2008, regarding the status of existing services offered
under paragraph 7
of Section 5-2. This report shall include, but not be limited to, the following
information:
(1) The number of persons who currently receive these | ||
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(2) The nature, scope, and cost of services.
(3) The comparative cost of providing those services | ||
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(4) The funding sources for the provision of | ||
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(5) The qualifications, skills, and availability of | ||
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(6) The number of children who have aged out of the | ||
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(Source: P.A. 95-331, eff. 8-21-07; 95-622, eff. 9-17-07.)
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(305 ILCS 5/5-2.06) Sec. 5-2.06. Payment rates; Children's Community-Based Health Care Centers. Beginning January 1, 2025 and subject to federal approval, the Department shall, for eligible individuals, reimburse Children's Community-Based Health Care Centers established in the Alternative Health Care Delivery Act and providing nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting and reuniting families for a maximum of up to 120 days on a per diem basis at the lower of the Children's Community-Based Health Care Center's usual and customary charge to the public or at the Department rate of $1,300. Payments at the rate set forth in this Section are exempt from the 2.7% rate reduction required under Section 5-5e.(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-2.07) Sec. 5-2.07. Use of Medicaid spend-down. No later than July 1, 2007, subject to federal approval of a State Medicaid Plan amendment, which shall be sought by the Department of Healthcare and Family Services or its successor agency, persons described in item 2(a) of Section 5-2, who fail to qualify for basic maintenance under Article III of this Code on the basis of need because of excess income or assets, or both, may establish eligibility for medical assistance by paying the amount of their monthly spend-down under this Article (as described in 42 CFR 435.831) to the Department of Healthcare and Family Services or its successor agency or by having a third party pay that amount to the Department on their behalf. A person who uses Medicaid spend-down to qualify for medical assistance shall be provided up to 6 consecutive months to submit and have medical receipts and bills processed by the Department as evidence of payment of the person's monthly spend-down amount before becoming ineligible for medical assistance under this Section.
(Source: P.A. 102-74, eff. 7-9-21.) |
(305 ILCS 5/5-2.08) Sec. 5-2.08. Spousal caregiver demonstration. (a) The Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall develop a demonstration project within the Home Services Program under which a spouse may be reimbursed for providing care to his or her spouse, who is eligible for services through the Home Services Program and who meets the criteria for this demonstration project. The demonstration project shall operate in selected counties and be limited to serving no more than 100 unduplicated persons in a State fiscal year. The components of the demonstration project shall include the following: (1) Authorization for a spouse to be reimbursed for | ||
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(2) The development of specific criteria for the | ||
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(3) The determination of the personal care or similar | ||
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(4) The method for determining that the amount of | ||
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(5) Limitations on the number of hours of personal | ||
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(6) Utilization of the Determination of Need | ||
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(7) Determination of how or whether the provision of | ||
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(8) Use of procedures that ensure that payments are | ||
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(9) Assurances that all other criteria of the | ||
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(10) Measurement of participant experiences. (11) Monthly in-home monitoring of the health and | ||
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(12) Documentation of the marital relationship for | ||
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(13) Assurances that the eligible spouse is capable | ||
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(14) Enrollment of an alternative care provider to | ||
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(15) Assurances that the spousal caregiver is | ||
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(b) By July 1, 2009, the Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall begin development of the demonstration project. The Department of Human Services shall provide an interim report on or before March 1, 2010 to the Governor and the General Assembly that includes the progress on the development of the demonstration project and implementation timelines of the demonstration project and the criteria for the demonstration project. (c) The Department of Human Services shall report findings and recommendations by March 1, 2011 to the Governor and the General Assembly. The report shall include an explanation of the manner in which each demonstration project component listed in paragraphs (1) through (10) of subsection (a) is addressed. In addition, the report shall include (i) the estimated number of clients statewide who could utilize services and (ii) an analysis of the fiscal impact per client on the Department's new and existing costs under the Home Services Program.
(Source: P.A. 96-351, eff. 8-13-09.) |
(305 ILCS 5/5-2.09) Sec. 5-2.09. Enhanced federal medical assistance percentage. In accordance with Section 9817 of the American Rescue Plan Act of 2021 (Pub. L. 117-2) and corresponding federal guidance, the Department of Healthcare and Family Services shall take appropriate actions to claim an enhanced federal medical assistance percentage (FMAP) provided by Section 9817 of the American Rescue Plan Act of 2021 with respect to expenditures under the State medical assistance program for home and community-based services from April 1, 2021 through March 31, 2022. The Department is authorized to use State funds equivalent to the amount of federal funds attributable to the increased federal medical assistance percentage under Section 9817 of the American Rescue Plan Act of 2021 to implement or supplement the implementation of activities to enhance, expand, or strengthen home and community based services under the State's medical assistance program to the extent permitted by and aligned with the goals of Section 9817 of the American Rescue Plan Act of 2021 through March 31, 2024 or any revised deadline established by the federal government. The use of such funds is subject to compliance with applicable federal requirements and federal approval, including the approval of any necessary State Plan Amendments, Waiver Amendments, or other federally required documents or assurances. The Department may adopt rules as necessary, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-16, eff. 6-17-21.) |
(305 ILCS 5/5-2.10) Sec. 5-2.10. Increased accountability for nursing facilities. The Department shall develop a plan for the revitalization of nursing homes licensed under the Nursing Home Care Act and shall report to the Governor and the General Assembly on a recommended course of action, including, but not limited to, the following: (1) significantly increasing federal funds by | ||
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(2)improving payments through increased funding and | ||
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(3)transitioning the methodologies for reimbursement | ||
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No later than September 30, 2021, the Department shall submit a report to the Governor and the General Assembly, which outlines the steps taken by the Department, including discussions with interested stakeholders and industry representatives, and recommendations for further action by the General Assembly to provide for accountability and to achieve the program objectives outlined in this Section, which shall require action by the General Assembly.
(Source: P.A. 102-16, eff. 6-17-21.) |
(305 ILCS 5/5-2.1) (from Ch. 23, par. 5-2.1)
Sec. 5-2.1.
Property transfers.
(a) To the extent required under federal law, a person shall not make or
have made a voluntary or involuntary assignment or transfer of any legal or
equitable interests in real property or in personal property, whether vested,
contingent or inchoate, for less than fair market value. A person's interest in
real or personal property includes all income and assets to which the person is
entitled or to which the person would be entitled if the person had not taken
action to avoid receiving the interest.
(b) (Blank).
(c) (Blank).
(d) (Blank).
(e) (Blank).
(Source: P.A. 92-84, eff. 7-1-02.)
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(305 ILCS 5/5-2.1a)
Sec. 5-2.1a. Treatment of trust amounts. To the extent required by
federal
law, the Department of Healthcare and Family Services shall provide by rule for the consideration of
trusts and similar legal instruments or devices established by a person in the
Illinois Department's determination of the person's eligibility for and the
amount of assistance provided under this Article.
(Source: P.A. 98-651, eff. 6-16-14.)
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(305 ILCS 5/5-2.1d) Sec. 5-2.1d. Retroactive eligibility. An applicant for medical assistance may be eligible for up to 3 months prior to the date of application if the person would have been eligible for medical assistance at the time he or she received the services if he or she had applied, regardless of whether the individual is alive when the application for medical assistance is made. In determining financial eligibility for medical assistance for retroactive months, the Department shall consider the amount of income and resources and exemptions available to a person as of the first day of each of the backdated months for which eligibility is sought.
(Source: P.A. 97-689, eff. 6-14-12.) |
(305 ILCS 5/5-2.2) (from Ch. 23, par. 5-2.2)
Sec. 5-2.2.
Cooperation in establishing support obligation.
A
parent or other person having custody of the child or a spouse who fails or
refuses to comply with the requirements of Title XIX of the federal Social
Security Act, and the regulations duly promulgated thereunder, regarding
establishment and enforcement of the child or spousal support obligation
shall be ineligible for medical assistance and shall remain ineligible for
medical assistance for as long as the failure or refusal persists.
In addition to any other definition of failure or refusal to comply
with the requirements of Title XIX of the federal Social Security Act, in
the case of failure to attend court hearings, the parent or other person
can show cooperation by attending a court hearing or, if a court hearing
cannot be scheduled within 30 days following the court hearing that was
missed, by signing a statement that the parent or other person is now
willing to cooperate in the child support enforcement process and will
appear at any later scheduled court date. The parent or other person can
show cooperation by signing such a statement only once. If failure to
attend the court hearing or other failure to cooperate results in the case
being dismissed, such a statement may be signed after 2 months.
No denial or termination of medical assistance pursuant to this Section
shall commence during pregnancy of the parent or other person having
custody of the child or for 30 days after the termination of such pregnancy.
The termination of medical assistance may commence thereafter if the
Illinois Department determines that the failure or refusal to comply with
this Section persists. Postponement of denial or termination of medical
assistance during pregnancy under this paragraph shall be effective only to
the extent it does not conflict with federal law or regulation.
(Source: P.A. 85-1155.)
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(305 ILCS 5/5-2.3)
Sec. 5-2.3.
Notice of rights concerning institutionalization.
The
Illinois Department shall prepare a notice to be given to every applicant for
and recipient of medical assistance under this Article when the applicant or
recipient, or the spouse of the applicant or recipient, or a person for whom
the applicant or recipient is the primary caretaker, becomes an
institutionalized person. The notice shall fully and completely inform the
institutionalized person (and that person's spouse or primary caretaker, if
applicable) of each individual's rights and obligations under this Code with
respect to that institutionalization.
(Source: P.A. 88-162.)
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(305 ILCS 5/5-2.4)
Sec. 5-2.4. (Repealed).
(Source: P.A. 95-248, eff. 8-17-07. Repealed by P.A. 97-48, eff. 6-28-11.)
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(305 ILCS 5/5-3) (from Ch. 23, par. 5-3)
Sec. 5-3. Residence. Any person who has established his residence
in this State and lives therein, including any person who is a migrant
worker, may qualify for medical assistance. A person who, while
temporarily in this State, suffers injury or illness endangering his
life and health and necessitating emergency care, may also qualify.
Temporary absence from the State shall not disqualify a person from
maintaining his eligibility under this Article.
As used in this Section, "migrant worker" means any person residing
temporarily and employed in Illinois who moves seasonally from one
place to another for the purpose of employment in agricultural
activities, including the planting, raising, or harvesting of any
agricultural or horticultural commodities and the handling, packing, or
processing of such commodities on the farm where produced or at the
point of first processing, in animal husbandry, or in other activities connected
with the care of animals. Dependents of such person shall be
considered eligible if they are living with the person during his or her
temporary residence and employment in Illinois.
In order to be eligible for medical assistance under this section,
each migrant worker shall show proof of citizenship or legal immigration status.
(Source: P.A. 102-1030, eff. 5-27-22; 103-154, eff. 6-30-23.)
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(305 ILCS 5/5-4) (from Ch. 23, par. 5-4)
Sec. 5-4. Amount and nature of medical assistance. (a) The amount and nature of
medical assistance shall be determined in accordance
with the standards, rules, and regulations of the Department of Healthcare and Family Services, with due regard to the requirements and conditions in each case,
including contributions available from legally responsible
relatives. However, the amount and nature of such medical assistance shall
not be affected by the payment of any grant under the Senior Citizens and
Persons with Disabilities Property Tax Relief Act or any
distributions or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The amount and nature of medical assistance shall not be affected by the
receipt of donations or benefits from fundraisers in cases of serious
illness, as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement of
the donations or benefits.
In determining the income and resources available to the institutionalized
spouse and to the community spouse, the Department of Healthcare and Family Services
shall follow the procedures established by federal law. If an institutionalized spouse or community spouse refuses to comply with the requirements of Title XIX of the federal Social Security Act and the regulations duly promulgated thereunder by failing to provide the total value of assets, including income and resources, to the extent either the institutionalized spouse or community spouse has an ownership interest in them pursuant to 42 U.S.C. 1396r-5, such refusal may result in the institutionalized spouse being denied eligibility and continuing to remain ineligible for the medical assistance program based on failure to cooperate. Subject to federal approval, beginning January 1, 2023, the community spouse resource allowance shall be established and maintained as follows: a base amount of $109,560 plus an additional amount of $2,784 added to the base amount each year for a period of 10 years commencing with calendar year 2024 through calendar year 2034. In addition to the base amount and the additional amount shall be any increase each year from the prior year to the maximum resource allowance permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act. Subject to federal approval, beginning January 1, 2034 the community spouse resource allowance shall be established and maintained at the maximum amount permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing. Subject to federal approval, beginning January 1, 2023 the monthly maintenance allowance for the community spouse shall be
established and maintained at the maximum amount permitted pursuant to Section
1924(d)(3)(C) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. Subject
to the approval of the Secretary of the United States Department of Health and
Human Services, the provisions of this Section shall be extended to persons who
but for the provision of home or community-based services under Section
4.02 of the Illinois Act on the Aging, would require the level of care provided
in an institution, as is provided for in federal law.
(b) Spousal support for institutionalized spouses receiving medical assistance. (i) The Department may seek support for an | ||
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(ii) The Department may bring an action in the | ||
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(iii) Proceedings may be initiated to obtain support, | ||
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(iv) The orders for the payment of moneys for the | ||
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(Source: P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
Sec. 5-4.1. Co-payments. The Department may by rule provide that recipients under any Article of this Code shall pay a federally approved fee as a co-payment for services. No
co-payment requirement can exist
for renal dialysis, radiation therapy, cancer chemotherapy, or insulin, and
other products necessary on a recurring basis, the absence of which would
be life threatening, or where co-payment expenditures for required services
and/or medications for chronic diseases that the Illinois Department shall
by rule designate shall cause an extensive financial burden on the
recipient, and provided no co-payment shall exist for emergency room
encounters which are for medical emergencies. The Department shall seek approval of a State plan amendment that allows pharmacies to refuse to dispense drugs in circumstances where the recipient does not pay the required co-payment. Co-payments may not exceed $10 for emergency room use for a non-emergency situation as defined by the Department by rule and subject to federal approval.
(Source: P.A. 101-209, eff. 8-5-19.)
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(305 ILCS 5/5-4.2) Sec. 5-4.2. Ambulance services payments. (a) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section. It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for recipients of aid under this Article and to provide appropriate incentives to ambulance service providers to provide services in an efficient and cost-effective manner. Thus, it is the intent of the General Assembly that the Illinois Department implement a reimbursement system for ambulance services that, to the extent practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, is consistent with the payment principles of Medicare. To ensure uniformity between the payment principles of Medicare and Medicaid, the Illinois Department shall follow, to the extent necessary and practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, and manuals used to determine the amounts paid to ambulance service providers under Title XVIII of the Social Security Act (Medicare). (b) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1996, the Illinois Department shall reimburse ambulance service providers based upon the actual distance traveled if a natural disaster, weather conditions, road repairs, or traffic congestion necessitates the use of a route other than the most direct route. (c) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, air ambulance, medi-car, service car, or taxi. (c-1) For purposes of this Section, "ground ambulance service" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act. (c-2) For purposes of this Section, "ground ambulance service provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services. (c-3) For purposes of this Section, "medi-car" means transportation services provided to a patient who is confined to a wheelchair and requires the use of a hydraulic or electric lift or ramp and wheelchair lockdown when the patient's condition does not require medical observation, medical supervision, medical equipment, the administration of medications, or the administration of oxygen. (c-4) For purposes of this Section, "service car" means transportation services provided to a patient by a passenger vehicle where that patient does not require the specialized modes described in subsection (c-1) or (c-3). (c-5) For purposes of this Section, "air ambulance service" means medical transport by helicopter or airplane for patients, as defined in 29 U.S.C. 1185f(c)(1), and any service that is described as an air ambulance service by the federal Centers for Medicare and Medicaid Services. (d) This Section does not prohibit separate billing by ambulance service providers for oxygen furnished while providing advanced life support services. (e) Beginning with services rendered on or after July 1, 2008, all providers of non-emergency medi-car and service car transportation must certify that the driver and employee attendant, as applicable, have completed a safety program approved by the Department to protect both the patient and the driver, prior to transporting a patient. The provider must maintain this certification in its records. The provider shall produce such documentation upon demand by the Department or its representative. Failure to produce documentation of such training shall result in recovery of any payments made by the Department for services rendered by a non-certified driver or employee attendant. Medi-car and service car providers must maintain legible documentation in their records of the driver and, as applicable, employee attendant that actually transported the patient. Providers must recertify all drivers and employee attendants every 3 years. If they meet the established training components set forth by the Department, providers of non-emergency medi-car and service car transportation that are either directly or through an affiliated company licensed by the Department of Public Health shall be approved by the Department to have in-house safety programs for training their own staff. Notwithstanding the requirements above, any public transportation provider of medi-car and service car transportation that receives federal funding under 49 U.S.C. 5307 and 5311 need not certify its drivers and employee attendants under this Section, since safety training is already federally mandated. (f) With respect to any policy or program administered by the Department or its agent regarding approval of non-emergency medical transportation by ground ambulance service providers, including, but not limited to, the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), the Department shall establish by rule a process by which ground ambulance service providers of non-emergency medical transportation may appeal any decision by the Department or its agent for which no denial was received prior to the time of transport that either (i) denies a request for approval for payment of non-emergency transportation by means of ground ambulance service or (ii) grants a request for approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than the ground ambulance service provider would have received as compensation for the level of service requested. The rule shall be filed by December 15, 2012 and shall provide that, for any decision rendered by the Department or its agent on or after the date the rule takes effect, the ground ambulance service provider shall have 60 days from the date the decision is received to file an appeal. The rule established by the Department shall be, insofar as is practical, consistent with the Illinois Administrative Procedure Act. The Director's decision on an appeal under this Section shall be a final administrative decision subject to review under the Administrative Review Law. (f-5) Beginning 90 days after July 20, 2012 (the effective date of Public Act 97-842), (i) no denial of a request for approval for payment of non-emergency transportation by means of ground ambulance service, and (ii) no approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than would have been received at the level of service submitted by the ground ambulance service provider, may be issued by the Department or its agent unless the Department has submitted the criteria for determining the appropriateness of the transport for first notice publication in the Illinois Register pursuant to Section 5-40 of the Illinois Administrative Procedure Act. (f-6) Within 90 days after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, the Department shall file rules to allow for the approval of ground ambulance services when the sole purpose of the transport is for the navigation of stairs or the assisting or lifting of a patient at a medical facility or during a medical appointment in instances where the Department or a contracted Medicaid managed care organization or their transportation broker is unable to secure transportation through any other transportation provider. (f-7) For non-emergency ground ambulance claims properly denied under Department policy at the time the claim is filed due to failure to submit a valid Medical Certification for Non-Emergency Ambulance on and after December 15, 2012 and prior to January 1, 2021, the Department shall allot $2,000,000 to a pool to reimburse such claims if the provider proves medical necessity for the service by other means. Providers must submit any such denied claims for which they seek compensation to the Department no later than December 31, 2021 along with documentation of medical necessity. No later than May 31, 2022, the Department shall determine for which claims medical necessity was established. Such claims for which medical necessity was established shall be paid at the rate in effect at the time of the service, provided the $2,000,000 is sufficient to pay at those rates. If the pool is not sufficient, claims shall be paid at a uniform percentage of the applicable rate such that the pool of $2,000,000 is exhausted. The appeal process described in subsection (f) shall not be applicable to the Department's determinations made in accordance with this subsection. (g) Whenever a patient covered by a medical assistance program under this Code or by another medical program administered by the Department, including a patient covered under the State's Medicaid managed care program, is being transported from a facility and requires non-emergency transportation including ground ambulance, medi-car, or service car transportation, a Physician Certification Statement as described in this Section shall be required for each patient. Facilities shall develop procedures for a licensed medical professional to provide a written and signed Physician Certification Statement. The Physician Certification Statement shall specify the level of transportation services needed and complete a medical certification establishing the criteria for approval of non-emergency ambulance transportation, as published by the Department of Healthcare and Family Services, that is met by the patient. This certification shall be completed prior to ordering the transportation service and prior to patient discharge. The Physician Certification Statement is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome. If the ground ambulance provider, medi-car provider, or service car provider is unable to obtain the required Physician Certification Statement within 10 calendar days following the date of the service, the ground ambulance provider, medi-car provider, or service car provider must document its attempt to obtain the requested certification and may then submit the claim for payment. Acceptable documentation includes a signed return receipt from the U.S. Postal Service, facsimile receipt, email receipt, or other similar service that evidences that the ground ambulance provider, medi-car provider, or service car provider attempted to obtain the required Physician Certification Statement. The medical certification specifying the level and type of non-emergency transportation needed shall be in the form of the Physician Certification Statement on a standardized form prescribed by the Department of Healthcare and Family Services. Within 75 days after July 27, 2018 (the effective date of Public Act 100-646), the Department of Healthcare and Family Services shall develop a standardized form of the Physician Certification Statement specifying the level and type of transportation services needed in consultation with the Department of Public Health, Medicaid managed care organizations, a statewide association representing ambulance providers, a statewide association representing hospitals, 3 statewide associations representing nursing homes, and other stakeholders. The Physician Certification Statement shall include, but is not limited to, the criteria necessary to demonstrate medical necessity for the level of transport needed as required by (i) the Department of Healthcare and Family Services and (ii) the federal Centers for Medicare and Medicaid Services as outlined in the Centers for Medicare and Medicaid Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician Certification Statement shall satisfy the obligations of hospitals under Section 6.22 of the Hospital Licensing Act and nursing homes under Section 2-217 of the Nursing Home Care Act. Implementation and acceptance of the Physician Certification Statement shall take place no later than 90 days after the issuance of the Physician Certification Statement by the Department of Healthcare and Family Services. Pursuant to subsection (E) of Section 12-4.25 of this Code, the Department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification. Beginning October 1, 2018, the Department of Healthcare and Family Services shall collect data from Medicaid managed care organizations and transportation brokers, including the Department's NETSPAP broker, regarding denials and appeals related to the missing or incomplete Physician Certification Statement forms and overall compliance with this subsection. The Department of Healthcare and Family Services shall publish quarterly results on its website within 15 days following the end of each quarter. (h) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (i) Subject to federal approval, on and after January 1, 2024, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers not participating in the Ground Emergency Medical Transportation (GEMT) Program for medical transportation services provided by means of a ground ambulance to a level not lower than 140% of the base rate in effect as of January 1, 2023. (j) For the purpose of understanding ground ambulance transportation services cost structures and their impact on the Medical Assistance Program, the Department shall engage stakeholders, including, but not limited to, a statewide association representing private ground ambulance service providers in Illinois, to develop recommendations for a plan for the regular collection of cost data for all ground ambulance transportation providers reimbursed under the Illinois Title XIX State Plan. Cost data obtained through this process shall be used to inform on and to ensure the effectiveness and efficiency of Illinois Medicaid rates. The Department shall establish a process to limit public availability of portions of the cost report data determined to be proprietary. This process shall be concluded and recommendations shall be provided no later than December 31, 2025. (k) Subject to federal approval, beginning on January 1, 2024, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for medical transportation services provided by means of an air ambulance to a level not lower than 50% of the Medicare ambulance fee schedule rates, by designated Medicare locality, in effect on January 1, 2023. (Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article 70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section 80-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-4.20)
Sec. 5-4.20. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.21)
Sec. 5-4.21. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.22)
Sec. 5-4.22. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.23)
Sec. 5-4.23. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.24)
Sec. 5-4.24. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.25)
Sec. 5-4.25. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.26)
Sec. 5-4.26. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.27)
Sec. 5-4.27. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.28)
Sec. 5-4.28. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.29)
Sec. 5-4.29. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.30)
Sec. 5-4.30. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.31)
Sec. 5-4.31. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.32)
Sec. 5-4.32. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.33)
Sec. 5-4.33. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.34)
Sec. 5-4.34. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.35)
Sec. 5-4.35. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.36)
Sec. 5-4.36. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.37)
Sec. 5-4.37. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.38)
Sec. 5-4.38. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-4.39)
Sec. 5-4.39. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5) (Text of Section from P.A. 103-593, Article 5, Section 5-5) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Subject to federal approval, on and after January 1, 2025, the rates paid for sedation evaluation and the provision of deep sedation and intravenous sedation for the purpose of dental services shall be increased by 33% above the rates in effect on December 31, 2024. The rates paid for nitrous oxide sedation shall not be impacted by this paragraph and shall remain the same as the rates in effect on December 31, 2024. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24.) (Text of Section from P.A. 103-593, Article 90, Section 90-5) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. Subject to appropriation and to federal approval, the Department shall file administrative rules updating the Handicapping Labio-Lingual Deviation orthodontic scoring tool by January 1, 2025, or as soon as practicable. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593, Article 90, Section 90-5, eff. 6-7-24.) (Text of Section from P.A. 103-605) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-605, eff. 7-1-24.) (Text of Section from P.A. 103-808) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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(G) Molecular breast imaging (MBI) and MRI of an | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including radiologists that are trained in all forms of FDA approved breast imaging technologies, breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-808, eff. 1-1-26.) (Text of Section from P.A. 103-909) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, or (3) lifetime restriction limit mandate. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, also reimburse hospitals for costs associated with all newborn screening tests added on and after the effective date of this amendatory Act of the 103rd General Assembly to the Newborn Metabolic Screening Act and required to be performed under that Act at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-909, eff. 8-9-24.) (Text of Section from P.A. 103-1040) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing. Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article. Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval. Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the | ||
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(2) eyeglasses prescribed by a physician skilled in | ||
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On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession. On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program. Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision. On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for individuals 35 years of age or older who are eligible for medical assistance under this Article, as follows: (A) A baseline mammogram for individuals 35 to 39 | ||
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(B) An annual mammogram for individuals 40 years of | ||
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(C) A mammogram at the age and intervals considered | ||
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(D) A comprehensive ultrasound screening and MRI of | ||
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(E) A screening MRI when medically necessary, as | ||
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(F) A diagnostic mammogram when medically necessary, | ||
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The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223). All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section: "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography. "Diagnostic mammography" means a method of screening that is designed to evaluate an abnormality in a breast, including an abnormality seen or suspected on a screening mammogram or a subjective or objective abnormality otherwise detected in the breast. "Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. "Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph. On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after January 1, 2023 (the effective date of Public Act 102-1018), breast tomosynthesis. The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography. On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment. Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph. The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation. The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal. The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program. The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit. The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45. Subject to federal approval, the Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine for persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine. On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department. Any medical or health care provider shall immediately recommend, to any pregnant individual who is being provided prenatal services and is suspected of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services. All medical providers providing medical assistance to pregnant individuals under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted individuals, including information on appropriate referrals for other social services that may be needed by addicted individuals in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of the recipient's substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and | ||
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(2) The Department may elect to consider and | ||
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(3) Persons receiving medical services through | ||
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Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims. Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented. The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article. The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department. Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty. The Department has the discretion to limit the conditional enrollment period for vendors based upon the category of risk of the vendor. Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law. The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period. To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions: (1) In the case of a provider whose enrollment is in | ||
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(2) In the case of errors attributable to the | ||
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(3) In the case of a provider for whom the Illinois | ||
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(4) In the case of a provider operated by a unit of | ||
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For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer. In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed. Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims. To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records. The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation. Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre-adjudicated, or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services. The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs. The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement. In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of | ||
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(b) actual statistics and trends in the provision of | ||
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(c) current rate structures and proposed changes in | ||
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(d) efforts at utilization review and control by the | ||
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The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act. Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. Because kidney transplantation can be an appropriate, cost-effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation. Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria, (2) prior authorization mandate, (3) lifetime restriction limit mandate, or (4) limitations on dosage. On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program. Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection. A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center. Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022. Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws. Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative Care Act. Notwithstanding any other provision of this Code, within 12 months after June 2, 2022 (the effective date of Public Act 102-1037) and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph. Notwithstanding any other provision of this Code, the medical assistance program shall, subject to appropriation and federal approval, reimburse hospitals for costs associated with a newborn screening test for the presence of metachromatic leukodystrophy, as required under the Newborn Metabolic Screening Act, at a rate not less than the fee charged by the Department of Public Health. The Department shall seek federal approval before the implementation of the newborn screening test fees by the Department of Public Health. Notwithstanding any other provision of this Code, beginning on January 1, 2024, subject to federal approval, cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. Notwithstanding any other provision of this Code, medically necessary reconstructive services that are intended to restore physical appearance shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this paragraph, "reconstructive services" means treatments performed on structures of the body damaged by trauma to restore physical appearance. (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-1040, eff. 8-9-24.) |
(305 ILCS 5/5-5.01) (from Ch. 23, par. 5-5.01)
Sec. 5-5.01. The Department of Healthcare and Family Services may establish and implement
a pilot project for determining the feasibility of authorizing medical
assistance payments for the costs of diagnosis and treatment of Alzheimer's
disease.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/5-5.01a) (Text of Section from P.A. 103-593, Article 15, Section 15-5) Sec. 5-5.01a. Supportive living facilities program. (a) The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner. A supportive living facility is (i) a free-standing facility or (ii) a distinct physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units. Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards. (b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services. The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%. The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018. Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated. Subject to federal approval, beginning January 1, 2024, the dementia care rate for supportive living services must be no less than the non-dementia care supportive living services rate multiplied by 1.5. (b-5) Subject to federal approval, beginning January 1, 2025, Medicaid rates for supportive living services must be at least 54.75% of the average total nursing services per diem rate for the geographic areas defined by the Department and shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are | ||
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(2) those distinct parts of the site or building are | ||
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(3) those distinct parts of the site or building do | ||
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(4) those distinct parts of the site or building do | ||
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(e) Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act. (f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage. (g) All applications for the expansion of supportive living dementia care settings involving sites not approved by the Department on January 1, 2024 (the effective date of Public Act 103-102) may allow new elderly non-dementia units in addition to new dementia care units. The Department may approve such applications only if the application has: (1) no more than one non-dementia care unit for each dementia care unit and (2) the site is not located within 4 miles of an existing supportive living program site in Cook County (including the City of Chicago), not located within 12 miles of an existing supportive living program site in DuPage County, Kane County, Lake County, McHenry County, or Will County, or not located within 25 miles of an existing supportive living program site in any other county. (h) Beginning January 1, 2025, subject to federal approval, for a person who is a resident of a supportive living facility under this Section, the monthly personal needs allowance shall be $120 per month. (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593, Article 15, Section 15-5, eff. 6-7-24.) (Text of Section from P.A. 103-593, Article 100, Section 100-5) Sec. 5-5.01a. Supportive living facilities program. (a) The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner. A supportive living facility is (i) a free-standing facility or (ii) a distinct physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units. Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards. (b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services. The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%. The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018. Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated. Subject to federal approval, beginning January 1, 2024, the dementia care rate for supportive living services must be no less than the non-dementia care supportive living services rate multiplied by 1.5. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are | ||
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(2) those distinct parts of the site or building are | ||
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(3) those distinct parts of the site or building do | ||
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(4) those distinct parts of the site or building do | ||
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(e) Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act. (f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage. (g) All applications for the expansion of supportive living dementia care settings involving sites not approved by the Department by January 1, 2024 may allow new elderly non-dementia units in addition to new dementia care units. The Department may approve such applications only if the application has: (1) no more than one non-dementia care unit for each dementia care unit and (2) the site is not located within 4 miles of an existing supportive living program site in Cook County (including the City of Chicago), not located within 12 miles of an existing supportive living program site in Alexander, Bond, Boone, Calhoun, Champaign, Clinton, DeKalb, DuPage Fulton, Grundy, Henry, Jackson, Jersey, Johnson, Kane, Kankakee, Kendall, Lake, Macon, Macoupin, Madison, Marshall, McHenry, McLean, Menard, Mercer, Monroe, Peoria, Piatt, Rock Island, Sangamon, Stark, St. Clair, Tazewell, Vermilion, Will, Williamson, Winnebago, or Woodford counties, or not located within 25 miles of an existing supportive living program site in any other county. (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593, Article 100, Section 100-5, eff. 6-7-24.) (Text of Section from P.A. 103-593, Article 165, Section 165-5) Sec. 5-5.01a. Supportive living facilities program. (a) The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner. A supportive living facility is (i) a free-standing facility or (ii) a distinct physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units. Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards. (b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services. The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%. The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018. Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated. Subject to federal approval, beginning January 1, 2024, the dementia care rate for supportive living services must be no less than the non-dementia care supportive living services rate multiplied by 1.5. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are | ||
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(2) those distinct parts of the site or building are | ||
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(3) those distinct parts of the site or building do | ||
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(4) those distinct parts of the site or building do | ||
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(e) Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act. (f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage. (g) All applications for the expansion of supportive living dementia care settings involving sites not approved by the Department on January 1, 2024 (the effective date of Public Act 103-102) may allow new elderly non-dementia units in addition to new dementia care units. The Department may approve such applications only if the application has: (1) no more than one non-dementia care unit for each dementia care unit and (2) the site is not located within 4 miles of an existing supportive living program site in Cook County (including the City of Chicago), not located within 12 miles of an existing supportive living program site in DuPage County, Kane County, Lake County, McHenry County, or Will County, or not located within 25 miles of an existing supportive living program site in any other county. (h) As stated in the supportive living program home and community-based service waiver approved by the federal Centers for Medicare and Medicaid Services, and beginning July 1, 2025, the Department must maintain the rate add-on implemented on January 1, 2023 for the provision of 2 meals per day at no less than $6.15 per day. (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593, Article 165, Section 165-5, eff. 6-7-24.) (Text of Section from P.A. 103-605) Sec. 5-5.01a. Supportive living facilities program. (a) The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner. A supportive living facility is (i) a free-standing facility or (ii) a distinct physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units. Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards. (b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services. The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%. The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018. Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated. Subject to federal approval, beginning January 1, 2024, the dementia care rate for supportive living services must be no less than the non-dementia care supportive living services rate multiplied by 1.5. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are | ||
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(2) those distinct parts of the site or building are | ||
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(3) those distinct parts of the site or building do | ||
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(4) those distinct parts of the site or building do | ||
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(e) Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act. (f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage. (g) All applications for the expansion of supportive living dementia care settings involving sites not approved by the Department on January 1, 2024 (the effective date of Public Act 103-102) may allow new elderly non-dementia units in addition to new dementia care units. The Department may approve such applications only if the application has: (1) no more than one non-dementia care unit for each dementia care unit and (2) the site is not located within 4 miles of an existing supportive living program site in Cook County (including the City of Chicago), not located within 12 miles of an existing supportive living program site in DuPage County, Kane County, Lake County, McHenry County, or Will County, or not located within 25 miles of an existing supportive living program site in any other county. (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-605, eff. 7-1-24.) (Text of Section from P.A. 103-886) Sec. 5-5.01a. Supportive living facilities program. (a) The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner. A supportive living facility is (i) a free-standing facility or (ii) a distinct physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units. Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards. (b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services. The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%. The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018. Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated. Subject to federal approval, beginning January 1, 2024, the dementia care rate for supportive living services must be no less than the non-dementia care supportive living services rate multiplied by 1.5. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are | ||
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(2) those distinct parts of the site or building are | ||
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(3) those distinct parts of the site or building do | ||
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(4) those distinct parts of the site or building do | ||
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(e) Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act. (f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage. (g) All applications for the expansion of supportive living dementia care settings involving sites not approved by the Department on January 1, 2024 (the effective date of Public Act 103-102) may allow new elderly non-dementia units in addition to new dementia care units. The Department may approve such applications only if the application has: (1) no more than one non-dementia care unit for each dementia care unit and (2) the site is not located within 4 miles of an existing supportive living program site in Cook County (including the City of Chicago), not located within 12 miles of an existing supportive living program site in DuPage County, Kane County, Lake County, McHenry County, or Will County, or not located within 25 miles of an existing supportive living program site in any other county. (f) Subject to federal approval, the Department shall allow a certified medication aide to administer medication in a supportive living facility. For purposes of this subsection, "certified medication aide" means a person who has met the qualifications for certification under Section 79 of the Assisted Living and Shared Housing Act and assists with medication administration while under the supervision of a registered professional nurse as authorized by Section 50-75 of the Nurse Practice Act. The Department may adopt rules to implement this subsection. (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-886, eff. 8-9-24.) |
(305 ILCS 5/5-5.01b) Sec. 5-5.01b. Certified Nursing Assistant Intern Program. (a) The Department shall establish or approve a Certified Nursing Assistant Intern Program to address the increasing need for trained health care workers for the supporting living facilities program established under Section 5-5.01a. Upon successful completion of the classroom education and on-the-job training requirements of the Program under this Section, an individual may provide, at a facility certified under this Act, the patient and resident care services determined under the Program and may perform the procedures listed under subsection (d). (b) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 8 hours of classroom education on the services and procedures listed under subsection (d). The classroom education shall be: (1) taken within the facility where the certified | ||
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(2) proctored by either an advanced practice | ||
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(3) satisfied by the successful completion of an | ||
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(c) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 24 hours of on-the-job training in the services and procedures determined under the Program and listed under subsection (d), as follows: (1) The training program instructor shall be either | ||
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(2) The training program instructor shall ensure that | ||
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(3) All on-the-job training shall be under the direct | ||
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(4) All on-the-job training shall be conducted at a | ||
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(d) A certified nursing assistant intern shall receive classroom and on-the-job training on how to provide the patient or resident care services and procedures, as determined under the Program, that are required of a certified nursing assistant's performance skills, including, but not limited to, all of the following: (1) Successful completion and maintenance of active | ||
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(2) Infection control and in-service training | ||
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(3) Washing a resident's hands. (4) Performing oral hygiene on a resident. (5) Shaving a resident with an electric razor. (6) Giving a resident a partial bath. (7) Making a bed that is occupied. (8) Dressing a resident. (9) Transferring a resident to a wheelchair using a | ||
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(10) Ambulating a resident with a gait belt or | ||
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(11) Feeding a resident. (12) Calculating a resident's intake and output. (13) Placing a resident in a side-lying position. (14) The Heimlich maneuver. (e) A certified nursing assistant intern may not perform any of the following on a resident: (1) Shaving with a nonelectric razor. (2) Nail care. (3) Perineal care. (4) Transfer using a mechanical lift. (5) Passive range of motion. (f) A certified nursing assistant intern may only provide the patient or resident care services and perform the procedures that he or she is deemed qualified to perform that are listed under subsection (d). A certified nursing assistant intern may not provide the procedures excluded under subsection (e). (g) A certified nursing assistant intern shall report to a facility's charge nurse or nursing supervisor and may only be assigned duties authorized in this Section by a supervising nurse. (h) A facility shall notify its certified and licensed staff members, in writing, that a certified nursing assistant intern may only provide the services and perform the procedures listed under subsection (d). The notification shall detail which duties may be delegated to a certified nursing assistant intern. (i) If a facility learns that a certified nursing assistant intern is performing work outside of the scope of the Program's training, the facility shall: (1) stop the certified nursing assistant intern from | ||
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(2) inspect the work and correct mistakes, if the | ||
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(3) assign the work to the appropriate personnel; and (4) ensure that a thorough assessment of any resident | ||
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(j) The Program is subject to the Health Care Worker Background Check Act and the Health Care Worker Background Check Code under 77 Ill. Adm. Code 955. Program participants and personnel shall be included on the Health Care Worker Registry. (k) A Program participant who has completed the training required under paragraph (5) of subsection (a) of Section 3-206 of the Nursing Home Care Act, has completed the Program from April 21, 2020 through September 18, 2020, and has shown competency in all of the performance skills listed under subsection (d) shall be considered a certified nursing assistant intern. (l) The requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student must pass a BNATP written competency examination within 12 months after the completion of the BNATP does not apply to a certified nursing assistant intern under this Section. However, upon a Program participant's enrollment in a certified nursing assistant course, the requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student pass a BNATP written competency examination within 12 months after completion of the BNATP program applies. (m) A certified nursing assistant intern shall enroll in a certified nursing assistant program within 6 months after completing his or her certified nursing assistant intern training under the Program. The individual may continue to work as a certified nursing assistant intern during his or her certified nursing assistant training. If the scope of work for a nurse assistant in training pursuant to 77 Ill. Adm. Code 300.660 is broader in scope than the work permitted to be performed by a certified nursing assistant intern, then the certified nursing assistant intern enrolled in certified nursing assistant training may perform the work allowed under 77. Ill. Adm. Code 300.660. The individual shall receive one hour of credit for every hour employed as a certified nursing assistant intern or as a temporary nurse assistant, not to exceed 30 hours of credit, subject to the approval of an accredited certified nursing assistant training program. (n) A facility that seeks to train and employ a certified nursing assistant intern at the facility must: (1) not have received a substantiated citation, that | ||
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(2) establish a certified nursing assistant intern | ||
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(o) A facility that does not meet the requirements of subsection (n) shall cease its new employment training, education, or onboarding of any employee under the Program. The facility may resume its new employment training, education, or onboarding of an employee under the Program once the Department determines that the facility is in compliance with subsection (n). (p) To study the effectiveness of the Program, the Department shall collect data from participating facilities and publish a report on the extent to which the Program brought individuals into continuing employment as certified nursing assistants in long-term care. Data collected from facilities shall include, but shall not be limited to, the number of certified nursing assistants employed, the number of persons who began participation in the Program, the number of persons who successfully completed the Program, and the number of persons who continue employment in a long-term care service or facility. The report shall be published no later than 6 months after the Program end date determined under subsection (r). A facility participating in the Program shall, twice annually, submit data under this subsection in a manner and time determined by the Department. Failure to submit data under this subsection shall result in suspension of the facility's Program. (q) The Department may adopt emergency rules in accordance with Section 5-45.32 of the Illinois Administrative Procedure Act. (r) The Program shall end upon the termination of the Secretary of Health and Human Services' public health emergency declaration for COVID-19 or 3 years after the date that the Program becomes operational, whichever occurs later. (s) This Section is inoperative 18 months after the Program end date determined under subsection (r).
(Source: P.A. 102-1037, eff. 6-2-22; 103-154, eff. 6-30-23.) |
(305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
Sec. 5-5.02. Hospital reimbursements.
(a) Reimbursement to hospitals; July 1, 1992 through September 30, 1992.
Notwithstanding any other provisions of this Code or the Illinois
Department's Rules promulgated under the Illinois Administrative Procedure
Act, reimbursement to hospitals for services provided during the period
July 1, 1992 through September 30, 1992, shall be as follows:
(1) For inpatient hospital services rendered, or if | ||
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(2) For the purpose of calculating the inpatient | ||
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(3) For the purpose of calculating the inpatient | ||
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(b) Inpatient payments. For inpatient services provided on or after October
1, 1993, in addition to rates paid for hospital inpatient services pursuant to
the Illinois Health Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology, or any other
methodology used by the Illinois Department for inpatient services, the
Illinois Department shall make adjustment payments, in an amount calculated
pursuant to the methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any one of the
following requirements:
(1) Hospitals that are described in Section 1923 of | ||
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(2) Illinois hospitals that have a Medicaid inpatient | ||
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(3) Illinois hospitals that on July 1, 1991 had a | ||
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(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate | ||
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(B) also have a Medicaid obstetrical inpatient | ||
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(5) Any children's hospital, which means a hospital | ||
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(6) A hospital that reopens a previously closed | ||
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(c) Inpatient adjustment payments. The adjustment payments required by
paragraph (b) shall be calculated based upon the hospital's Medicaid
inpatient utilization rate as follows:
(1) hospitals with a Medicaid inpatient utilization | ||
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(2) hospitals with a Medicaid inpatient utilization | ||
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(3) hospitals with a Medicaid inpatient utilization | ||
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(4) hospitals with a Medicaid inpatient utilization | ||
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(5) hospitals qualifying under clause (6) of | ||
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(d) Supplemental adjustment payments. In addition to the adjustment
payments described in paragraph (c), hospitals as defined in clauses
(1) through (6) of paragraph (b), excluding county hospitals (as defined in
subsection (c) of Section 15-1 of this Code) and a hospital organized under the
University of Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX of the federal
Social Security Act, these supplemental adjustment payments shall not be
classified as adjustment payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in paragraphs (c) and (d)
shall be increased on October 1, 1993 and annually thereafter by a percentage
equal to the lesser of (i) the increase in the DRI hospital cost index for the
most recent 12 month period for which data are available, or (ii) the
percentage increase in the statewide average hospital payment rate over the
previous year's statewide average hospital payment rate. The sum of the
inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other
than a county hospital (as defined in subsection (c) of Section 15-1 of this
Code) or a hospital organized under the University of Illinois Hospital Act,
however, shall not exceed $275 per day; that limit shall be increased on
October 1, 1993 and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most recent 12-month
period for which data are available or (ii) the percentage increase in the
statewide average hospital payment rate over the previous year's statewide
average hospital payment rate.
(f) Children's hospital inpatient adjustment payments. For children's
hospitals, as defined in clause (5) of paragraph (b), the adjustment payments
required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments. For county hospitals,
as defined in subsection (c) of Section 15-1 of this Code, there shall be an
adjustment payment as determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms shall be defined
as follows:
(1) "Medicaid inpatient utilization rate" means a | ||
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(2) "Mean Medicaid inpatient utilization rate" means | ||
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(3) "Medicaid obstetrical inpatient utilization rate" | ||
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(i) Inpatient adjustment payment limit. In order to meet the limits
of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust
disproportionate share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment payments. For
hospitals organized under the University of Illinois Hospital Act, there shall
be an adjustment payment as determined by rules adopted by the Illinois
Department.
(k) The Illinois Department may by rule establish criteria for and develop
methodologies for adjustment payments to hospitals participating under this
Article.
(l) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (m) The Department shall establish a cost-based reimbursement methodology for determining payments to hospitals for approved graduate medical education (GME) programs for dates of service on and after July 1, 2018. (1) As used in this subsection, "hospitals" means the | ||
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(2) An amendment to the Illinois Title XIX State Plan | ||
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(A) inpatient days; (B) outpatient days; (C) direct costs; (D) indirect costs; (E) managed care days; (F) all stages of medical training and education | ||
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(G) patient care payments related to the | ||
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(3) The Department shall make all GME payments | ||
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(4) The Department shall promptly take all actions | ||
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(5) As used in this subsection, "managed care days" | ||
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(6) All payments under this Section are contingent | ||
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(7) The Department may adopt rules necessary to | ||
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(Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21; 102-886, eff. 5-17-22.)
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(305 ILCS 5/5-5.03)
Sec. 5-5.03.
Trauma center adjustment.
(a) For inpatient admissions on or after October 1, 1992 for trauma
injuries as defined in the Emergency Medical Services (EMS) Systems Act, in
addition to any other payments made under this Code, the Illinois Department
shall make adjustment payments, in an amount calculated under subsection (b) of
this Section, to hospitals located in the State of Illinois that are recognized
as Level I trauma centers (adult or pediatric) and to certain Level II trauma
centers as determined by the Illinois Department.
(b) Trauma center adjustment calculation.
(1) The funds used to make trauma center adjustment | ||
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(A) At least 50% of the amount of moneys | ||
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(B) All federal matching funds received by the | ||
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(2) The trauma center adjustment payments shall be | ||
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(3) Disbursements from the Trauma Center Fund shall | ||
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(4) Trauma center adjustment payments shall not be | ||
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(c) Definitions. As used in this Section, unless the context requires
otherwise:
"Trauma center adjustment year" means, beginning October 1, 1992, the 12
month period beginning on October 1 of the year and ending September 30 of
the following year.
"Trauma center base year" means State Fiscal Year 1991 for trauma center
adjustment payments calculated for the October 1, 1992 trauma center
adjustment year, State Fiscal Year 1992 for trauma center adjustment payments
calculated for the October 1, 1993 trauma center adjustment year, and so on
for each succeeding State Fiscal Year for trauma center adjustment payments
calculated for the trauma center adjustment year beginning October 1 of
that State Fiscal Year.
(Source: P.A. 87-1229.)
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(305 ILCS 5/5-5.04) Sec. 5-5.04. Persons living with HIV/AIDS. The Department of Public Aid may seek federal approval to expand access to health care for persons living with HIV/AIDS. Implementation of this Section is subject to appropriation.
(Source: P.A. 94-629, eff. 1-1-06.) |
(305 ILCS 5/5-5.4k) Sec. 5-5.4k. Payments for long-acting injectable medications for mental health or substance use disorders. Notwithstanding any other provision of this Code, effective for dates of service on and after January 1, 2022, the medical assistance program shall separately reimburse at the prevailing fee schedule, for long-acting injectable medications administered for mental health or substance use disorder in the hospital inpatient setting, and which are compliant with the prior authorization requirements of this Section. The Department, in consultation with a statewide association representing a majority of hospitals and Managed Care Organizations shall implement, by rule, reimbursement policy and prior authorization criteria for the use of long-acting injectable medications administered in the hospital inpatient setting for the treatment of mental health disorders.
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/5-5.05) Sec. 5-5.05. Hospitals; psychiatric services. (a) On and after January 1, 2024, the inpatient, per diem rate to be paid to a hospital for inpatient psychiatric services shall be not less than 90% of the per diem rate established in accordance with subsection (b-5) of this Section, subject to the provisions of Section 14-12.5. (b) For purposes of this Section, "hospital" means a hospital with a distinct part unit for psychiatric services. For purposes of this Section, "inpatient psychiatric services" means those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder. (b-5) Notwithstanding any other provision of this Section, the inpatient, per diem rate to be paid to all safety-net hospitals for inpatient psychiatric services on and after January 1, 2021 shall be at least $630, subject to the provisions of Section 14-12.5. (b-10) Notwithstanding any other provision of this Section, effective with dates of service on and after January 1, 2022, any general acute care hospital with more than 9,500 inpatient psychiatric Medicaid days in any calendar year shall be paid the inpatient per diem rate of no less than $630, subject to the provisions of Section 14-12.5. (c) No rules shall be promulgated to implement this Section. For purposes of this Section, "rules" is given the meaning contained in Section 1-70 of the Illinois Administrative Procedure Act. (d) (Blank). (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21; 103-102, eff. 6-16-23; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-5.05a) Sec. 5-5.05a. Reimbursement rates; community mental health centers. Notwithstanding the provisions of any other law,
reimbursement rates, including enhanced payment rates and rate
add-ons, for psychiatric and behavioral health services
provided in or by community mental health centers licensed or
certified by the Department of Human Services shall not be
lower than the rates for such services in effect on November 1,
2017. The Department of Healthcare and Family Services shall
apply for any waiver or State Plan amendment, if required, to
implement the reimbursement rates established in this Section.
Implementation of the reimbursement rates shall be contingent
on federal approval.
(Source: P.A. 100-587, eff. 6-4-18.) |
(305 ILCS 5/5-5.05b) Sec. 5-5.05b. Access to psychiatric treatment. Effective July 1, 2019, or as soon thereafter as practical and subject to federal approval, the Department shall allocate an amount of up to $40,000,000 to enhance access psychiatric treatment, including both reimbursement rates to individual physicians board certified in psychiatry as well as community mental health centers and other relevant providers.
(Source: P.A. 101-10, eff. 6-5-19.) |
(305 ILCS 5/5-5.05c) Sec. 5-5.05c. Access to physician services. The Department shall increase rates of reimbursement for physician services to as close to 60% of Medicare rates in effect as of January 1, 2020 utilizing the rates of Illinois Locality 99 facility rates.
(Source: P.A. 101-650, eff. 7-7-20.) |
(305 ILCS 5/5-5.05d) Sec. 5-5.05d. Academic detailing for behavioral health providers. The Department shall develop, in collaboration with associations representing behavioral health providers, a program designed to provide behavioral health providers and providers in academic medical settings who need assistance in caring for patients with severe mental illness or a developmental disability under the medical assistance program with academic detailing and clinical consultation over the phone from a qualified provider on how to best care for the patient. The Department shall include the phone number on its website and notify providers that the service is available. The Department may create an in-person option if adequate staff is available. To the extent practicable, the Department shall build upon this service to address worker shortages and the availability of specialty services.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.05e) Sec. 5-5.05e. Tracking availability of beds for withdrawal management services. The Department of Human Services shall track, or contract with an organization to track, the availability of beds for withdrawal management services that are licensed by the Department and are available to medical assistance beneficiaries. The Department of Human Services shall update the tracking daily and publish the availability of beds online or in another public format.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.05f) Sec. 5-5.05f. Medicaid coverage for peer recovery support services. On or before January 1, 2023, the Department shall seek approval from the federal Centers for Medicare and Medicaid Services to cover peer recovery support services under the medical assistance program when rendered by certified peer support specialists for the purposes of supporting the recovery of individuals receiving substance use disorder treatment. As used in this Section, "certified peer support specialist" means an individual who: (1) is a self-identified current or former recipient | ||
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(2) is affiliated with a substance use prevention and | ||
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(A) is certified in accordance with applicable | ||
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(B) is certified as qualified to furnish peer | ||
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(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.05g) Sec. 5-5.05g. Alignment of substance use prevention and recovery and mental health policy. The Department and the Department of Human Services shall collaborate to review coverage and billing requirements for substance use prevention and recovery and mental health services with the goal of identifying disparities and streamlining coverage and billing requirements to reduce the administrative burden for providers and medical assistance beneficiaries.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.05h) Sec. 5-5.05h. Reimbursement rates for psychiatric evaluations and medication monitoring. Subject to federal approval, for dates of service on and after January 1, 2025, the Department shall make a one-time adjustment to the add-on rates for services delivered by physicians who are board-certified in psychiatry and advanced practice registered nurses who hold a current certification in psychiatric and mental health nursing. The one-time adjustment shall increase the add-on rates so that the sum of the Department's base per service unit rate plus the rate add-on is no less than $264.42 per hour adjusted for time and intensity as determined by the work relative value units in the 2024 national Medicare physician fee schedule, indexed to 60 minutes of individual psychotherapy.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5.06) Sec. 5-5.06. Dental home initiative. The Department, in cooperation with the dental community and other affected organizations such as Head Start, shall work to develop and promote the concept of a dental home for children covered under this Article. Included in this dental home outreach should be an effort to ensure an ongoing relationship between the patient and the dentist with an effort to provide comprehensive, coordinated, oral health care so that all children covered under this Article have access to preventative and restorative oral health care.
(Source: P.A. 97-283, eff. 8-9-11.) |
(305 ILCS 5/5-5.06a) Sec. 5-5.06a. Increased funding for dental services. Beginning January 1, 2022, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/5-5.06b) Sec. 5-5.06b. Dental services. On and after July 1, 2021, dental services provided to adults and children under the medical assistance program may be established and paid at no less than the rates published by the Department and effective January 1, 2020 for all local health departments as the fee schedule for children and adult recipients but shall include the following dental procedures and amounts: D0140 $19.12, D0150 $24.84, D0220 $6.61, D0230 $4.48, D0272 $11.09, D0274 $19.94, D1110 $48.38, D2140 $36.40, D2150 $56.82, D2391 $36.40, D2392 $56.82, D5110 $444.09, D5120 $444.09, D7140 $46.16, D7210 $67.73.
(Source: P.A. 102-16, eff. 6-17-21.) |
(305 ILCS 5/5-5.06c) Sec. 5-5.06c. Access to prenatal and postpartum care. To ensure access to high quality prenatal and postpartum care and to promote continuity of care for pregnant individuals, the Department shall increase the rate for prenatal and postpartum visits to no less than the rate for an adult well visit, including any applicable add-ons, beginning on January 1, 2023. Bundled rates that include prenatal or postpartum visits shall incorporate this increased rate, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.06d) Sec. 5-5.06d. External cephalic version rate. To encourage provider use of external cephalic versions and decrease the rates of caesarean sections in Illinois, the Department shall evaluate the rate for external cephalic versions and increase the rate by an amount determined by the Department to promote safer birthing options for pregnant individuals, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.06e) Sec. 5-5.06e. Increased funding for dental services. Beginning January 1, 2023, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-5.07) Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem rate. The Department of Children and Family Services shall pay the DCFS per diem rate for inpatient psychiatric stay at a free-standing psychiatric hospital or a hospital with a pediatric or adolescent inpatient psychiatric unit effective the 3rd day when a child is in the hospital beyond medical necessity, and the parent or caregiver has denied the child access to the home and has refused or failed to make provisions for another living arrangement for the child or the child's discharge is being delayed due to a pending inquiry or investigation by the Department of Children and Family Services. If any portion of a hospital stay is reimbursed under this Section, the hospital stay shall not be eligible for payment under the provisions of Section 14-13 of this Code.(Source: P.A. 102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff. 6-2-22; 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5.08) Sec. 5-5.08. Dialysis center funding. Notwithstanding any other provision of law, the add-on Medicaid payments to hospitals and freestanding chronic dialysis centers established under 89 Illinois Administrative Code 148.140(g)(4) for dates of service July 1, 2013 through June 30, 2015 is restored and in effect for dates of service on and after July 1, 2015 with no end date for such payments.
(Source: P.A. 100-23, eff. 7-6-17.) |
(305 ILCS 5/5-5.1) (from Ch. 23, par. 5-5.1)
Sec. 5-5.1. Grouping of facilities. The Department of Healthcare and Family Services shall, for purposes of payment, provide for
groupings of nursing facilities. Factors to be considered
in grouping facilities may include, but are not limited to,
size, age, patient mix, percentage of Medicaid funded residents, or geographical area.
The groupings developed under this Section shall be
considered in determining reasonable cost reimbursement
formulas. However, this Section shall not preclude the
Department from recognizing and evaluating the cost of
capital on a facility-by-facility basis.
A resident of a nursing facility whose application for long term care benefits is awaiting final action shall be included in the calculation as a Medicaid funded resident.(Source: P.A. 99-684, eff. 1-1-17.)
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(305 ILCS 5/5-5.2) Sec. 5-5.2. Payment. (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services. (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers. (c) (Blank). (c-1) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Patient Driven Payment Model (PDPM) has been fully operationalized, which shall take effect for services provided on or after the implementation of the PDPM reimbursement system begins. For the purposes of Public Act 102-1035, the implementation date of the PDPM reimbursement system and all related provisions shall be July 1, 2022 if the following conditions are met: (i) the Centers for Medicare and Medicaid Services has approved corresponding changes in the reimbursement system and bed assessment; and (ii) the Department has filed rules to implement these changes no later than June 1, 2022. Failure of the Department to file rules to implement the changes provided in Public Act 102-1035 no later than June 1, 2022 shall result in the implementation date being delayed to October 1, 2022. (d) The new nursing services reimbursement methodology utilizing the Patient Driven Payment Model, which shall be referred to as the PDPM reimbursement system, taking effect July 1, 2022, upon federal approval by the Centers for Medicare and Medicaid Services, shall be based on the following: (1) The methodology shall be resident-centered, | ||
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(2) Costs shall be annually rebased and case mix | ||
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(3) Regional wage adjustors based on the Health | ||
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(4) PDPM nursing case mix indices in effect on March | ||
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(5) The pool of funds available for distribution by | ||
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(6) The Department shall establish a variable per | ||
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Beginning October 1, 2024, the staffing percentage | ||
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(6.5) Beginning July 1, 2024, the paid per diem | ||
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(A) For the quarter beginning October 1, 2024, | ||
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(B) For the quarter beginning January 1, 2025, | ||
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(C) For the quarter beginning March 1, 2025, the | ||
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(D) For the quarter beginning July 1, 2025, the | ||
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Facilities with at least 70% of the staffing | ||
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(7) For dates of services beginning July 1, 2022, the | ||
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(A) for the quarter beginning July 1, 2022, the | ||
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(B) for the quarter beginning October 1, 2022, | ||
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(C) for the quarter beginning January 1, 2023, | ||
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(D) for the quarter beginning April 1, 2023, the | ||
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(E) for the quarter beginning July 1, 2023, the | ||
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(F) for the quarter beginning October 1, 2023 and | ||
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(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate. (1) Base rate spending pool shall be: (A) The base year resident days which are | ||
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(B) Each facility's nursing component per diem in | ||
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(C) Thirteen million is added to the product of | ||
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(2) For each nursing home with Medicaid residents as | ||
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(A) Base year resident days as calculated in | ||
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(B) The nursing home's regional wage adjustor | ||
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(C) Facility weighted case mix which is the | ||
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(D) The sum of the products calculated for each | ||
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(3) The Statewide RUG-IV nursing base per diem rate: (A) on January 1, 2014 shall be the quotient of | ||
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(B) on and after July 1, 2014 and until July 1, | ||
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(C) beginning July 1, 2022 and thereafter, $7 | ||
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(4) Minimum Data Set (MDS) comprehensive assessments | ||
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(5) Nursing facilities designated as of July 1, 2012 | ||
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(e) Beginning July 1, 2014, the Department shall allocate funding in the amount up to $10,000,000 for per diem add-ons to the RUGS methodology for dates of service on and after July 1, 2014: (1) $0.63 for each resident who scores in I4200 | ||
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(2) $2.67 for each resident who scores either a "1" | ||
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(e-1) (Blank). (e-2) For dates of services beginning January 1, 2014 and ending September 30, 2023, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. For dates of service beginning July 1, 2022 and ending September 30, 2023, the Medicaid access adjustment described in subsection (e-3) shall be added to the product. (e-3) A Medicaid Access Adjustment of $4 adjusted for the facility average PDPM case mix index calculated quarterly shall be added to the statewide PDPM nursing per diem for all facilities with annual Medicaid bed days of at least 70% of all occupied bed days adjusted quarterly. For each new calendar year and for the 6-month period beginning July 1, 2022, the percentage of a facility's occupied bed days comprised of Medicaid bed days shall be determined by the Department quarterly. For dates of service beginning January 1, 2023, the Medicaid Access Adjustment shall be increased to $4.75. This subsection shall be inoperative on and after January 1, 2028. (e-4) Subject to federal approval, on and after January 1, 2024, the Department shall increase the rate add-on at paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335 for ventilator services from $208 per day to $481 per day. Payment is subject to the criteria and requirements under 89 Ill. Adm. Code 147.335. (f) (Blank). (g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows: (1) (Blank); (2) (Blank); (3) Facility rates for the capital and support | ||
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(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%. (i) On and after July 1, 2014, the reimbursement rates for the support component of the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities shall be the rate in effect on June 30, 2014 increased by 8.17%. (i-1) Subject to federal approval, on and after January 1, 2024, the reimbursement rates for the support component of the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities shall be the rate in effect on June 30, 2023 increased by 12%. (j) Notwithstanding any other provision of law, subject to federal approval, effective July 1, 2019, sufficient funds shall be allocated for changes to rates for facilities licensed under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities for dates of services on and after July 1, 2019: (i) to establish, through June 30, 2022 a per diem add-on to the direct care per diem rate not to exceed $70,000,000 annually in the aggregate taking into account federal matching funds for the purpose of addressing the facility's unique staffing needs, adjusted quarterly and distributed by a weighted formula based on Medicaid bed days on the last day of the second quarter preceding the quarter for which the rate is being adjusted. Beginning July 1, 2022, the annual $70,000,000 described in the preceding sentence shall be dedicated to the variable per diem add-on for staffing under paragraph (6) of subsection (d); and (ii) in an amount not to exceed $170,000,000 annually in the aggregate taking into account federal matching funds to permit the support component of the nursing facility rate to be updated as follows: (1) 80%, or $136,000,000, of the funds shall be used | ||
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(2) After completing the calculation in paragraph | ||
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(3) The remainder of the 20%, or $34,000,000, shall | ||
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(k) During the first quarter of State Fiscal Year 2020, the Department of Healthcare of Family Services must convene a technical advisory group consisting of members of all trade associations representing Illinois skilled nursing providers to discuss changes necessary with federal implementation of Medicare's Patient-Driven Payment Model. Implementation of Medicare's Patient-Driven Payment Model shall, by September 1, 2020, end the collection of the MDS data that is necessary to maintain the current RUG-IV Medicaid payment methodology. The technical advisory group must consider a revised reimbursement methodology that takes into account transparency, accountability, actual staffing as reported under the federally required Payroll Based Journal system, changes to the minimum wage, adequacy in coverage of the cost of care, and a quality component that rewards quality improvements. (l) The Department shall establish per diem add-on payments to improve the quality of care delivered by facilities, including: (1) Incentive payments determined by facility | ||
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(A) Each quality pool must be distributed by | ||
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(B) Star rating weights are assigned based on the | ||
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(i) Zero-star or one-star rating has a weight | ||
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(ii) Two-star rating has a weight of 0.75. (iii) Three-star rating has a weight of 1.5. (iv) Four-star rating has a weight of 2.5. (v) Five-star rating has a weight of 3.5. (C) Each nursing home's quality weight score is | ||
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(D) The quality pool is no less than $70,000,000 | ||
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(E) The Department shall review quality metrics | ||
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(F) The Department shall disburse quality pool | ||
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(G) The Department shall publish any changes in | ||
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(2) Payments based on CNA tenure, promotion, and CNA | ||
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(m) The Department shall work with nursing facility industry representatives to design policies and procedures to permit facilities to address the integrity of data from federal reporting sites used by the Department in setting facility rates. (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102, Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50, Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-5.3) (from Ch. 23, par. 5-5.3)
Sec. 5-5.3. Conditions of Payment - Prospective Rates -
Accounting Principles. This amendatory Act establishes certain
conditions for the Department of Healthcare and Family Services in instituting
rates for the care of recipients of medical assistance in
nursing facilities and ICF/DDs.
Such conditions shall assure a method under which the payment
for nursing facility and ICF/DD services provided
to recipients under the Medical Assistance Program shall be
on a reasonable cost related basis, which is prospectively
determined at least annually by the Department of Public Aid (now Healthcare and Family Services).
The annually established payment rate shall take effect on July 1 in 1984
and subsequent years. There shall be no rate increase during calendar year
1983 and the first six months of calendar year 1984.
The determination of the payment shall be made on the
basis of generally accepted accounting principles that
shall take into account the actual costs to the facility
of providing nursing facility and ICF/DD services
to recipients under the medical assistance program.
The resultant total rate for a specified type of service
shall be an amount which shall have been determined to be
adequate to reimburse allowable costs of a facility that
is economically and efficiently operated. The Department
shall establish an effective date for each facility or group
of facilities after which rates shall be paid on a reasonable
cost related basis which shall be no sooner than the effective
date of this amendatory Act of 1977.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4) Sec. 5-5.4. Standards of payment; Department of Healthcare and Family Services. The Department of Healthcare and Family Services shall develop standards of payment of nursing facility and ICF/DD services in facilities providing such services under this Article which: (1) Provide for the determination of a facility's payment for nursing facility or ICF/DD services on a prospective basis. The amount of the payment rate for all nursing facilities certified by the Department of Public Health under the ID/DD Community Care Act or the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities, Long Term Care for Under Age 22 facilities, Skilled Nursing facilities, or Intermediate Care facilities under the medical assistance program shall be prospectively established annually on the basis of historical, financial, and statistical data reflecting actual costs from prior years, which shall be applied to the current rate year and updated for inflation, except that the capital cost element for newly constructed facilities shall be based upon projected budgets. The annually established payment rate shall take effect on July 1 in 1984 and subsequent years. No rate increase and no update for inflation shall be provided on or after July 1, 1994, unless specifically provided for in this Section. The changes made by Public Act 93-841 extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1998 shall include an increase of 3%. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2009 shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities the rates taking effect within 30 days after July 6, 2017 (the effective date of Public Act 100-23) shall include an increase sufficient to provide a $0.75 per hour wage increase for non-executive staff. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, the rates taking effect within 30 days after June 5, 2019 (the effective date of Public Act 101-10) shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% and, for services provided on or after October 1, 1999, shall be increased by $4.00 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, a new payment methodology must be implemented for the nursing component of the rate effective July 1, 2003. The Department of Public Aid (now Healthcare and Family Services) shall develop the new payment methodology using the Minimum Data Set (MDS) as the instrument to collect information concerning nursing home resident condition necessary to compute the rate. The Department shall develop the new payment methodology to meet the unique needs of Illinois nursing home residents while remaining subject to the appropriations provided by the General Assembly. A transition period from the payment methodology in effect on June 30, 2003 to the payment methodology in effect on July 1, 2003 shall be provided for a period not exceeding 3 years and 184 days after implementation of the new payment methodology as follows: (A) For a facility that would receive a lower nursing | ||
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(B) For a facility that would receive a higher | ||
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(C) Notwithstanding paragraphs (A) and (B), the | ||
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For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on March 1, 2001 shall include a statewide increase of 7.85%, as defined by the Department. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, except facilities participating in the Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, the numerator of the ratio used by the Department of Healthcare and Family Services to compute the rate payable under this Section using the Minimum Data Set (MDS) methodology shall incorporate the following annual amounts as the additional funds appropriated to the Department specifically to pay for rates based on the MDS nursing component methodology in excess of the funding in effect on December 31, 2006: (i) For rates taking effect January 1, 2007, | ||
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(ii) For rates taking effect January 1, 2008, | ||
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(iii) For rates taking effect January 1, 2009, | ||
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(iv) For rates taking effect April 1, 2011, or the | ||
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Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on April 1, 2002 shall include a statewide increase of 2.0%, as defined by the Department. This increase terminates on July 1, 2002; beginning July 1, 2002 these rates are reduced to the level of the rates in effect on March 31, 2002, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports on file with the Department of Public Aid no later than April 1, 2000, updated for inflation to January 1, 2001. For rates effective July 1, 2001 only, rates shall be the greater of the rate computed for July 1, 2001 or the rate effective on June 30, 2001. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the Illinois Department shall determine by rule the rates taking effect on July 1, 2002, which shall be 5.9% less than the rates in effect on June 30, 2002. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take effect only upon approval and implementation of the payment methodologies required under Section 5A-12. Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators. Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013, a socio-development component rate equal to 6.6% of the facility's nursing component rate as of January 1, 2006 shall be established and paid effective July 1, 2006. The socio-development component of the rate shall be increased by a factor of 2.53 on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707). As of August 1, 2008, the socio-development component rate shall be equal to 6.6% of the facility's nursing component rate as of January 1, 2006, multiplied by a factor of 3.53. For services provided on or after April 1, 2011, or the first day of the month that begins at least 45 days after February 16, 2011 (the effective date of Public Act 96-1530), whichever is later, the Illinois Department may by rule adjust these socio-development component rates, and may use different adjustment methodologies for those facilities participating, and those not participating, in the Illinois Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, but in no case may such rates be diminished below those in effect on August 1, 2008. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or as long-term care facilities for residents under 22 years of age, the rates taking effect on July 1, 2003 shall include a statewide increase of 4%, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707) shall include a statewide increase of 2.5%, as defined by the Department. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2005, facility rates shall be increased by the difference between (i) a facility's per diem property, liability, and malpractice insurance costs as reported in the cost report filed with the Department of Public Aid and used to establish rates effective July 1, 2001 and (ii) those same costs as reported in the facility's 2002 cost report. These costs shall be passed through to the facility without caps or limitations, except for adjustments required under normal auditing procedures. Rates established effective each July 1 shall govern payment for services rendered throughout that fiscal year, except that rates established on July 1, 1996 shall be increased by 6.8% for services provided on or after January 1, 1997. Such rates will be based upon the rates calculated for the year beginning July 1, 1990, and for subsequent years thereafter until June 30, 2001 shall be based on the facility cost reports for the facility fiscal year ending at any point in time during the previous calendar year, updated to the midpoint of the rate year. The cost report shall be on file with the Department no later than April 1 of the current rate year. Should the cost report not be on file by April 1, the Department shall base the rate on the latest cost report filed by each skilled care facility and intermediate care facility, updated to the midpoint of the current rate year. In determining rates for services rendered on and after July 1, 1985, fixed time shall not be computed at less than zero. The Department shall not make any alterations of regulations which would reduce any component of the Medicaid rate to a level below what that component would have been utilizing in the rate effective on July 1, 1984. (2) Shall take into account the actual costs incurred by facilities in providing services for recipients of skilled nursing and intermediate care services under the medical assistance program. (3) Shall take into account the medical and psycho-social characteristics and needs of the patients. (4) Shall take into account the actual costs incurred by facilities in meeting licensing and certification standards imposed and prescribed by the State of Illinois, any of its political subdivisions or municipalities and by the U.S. Department of Health and Human Services pursuant to Title XIX of the Social Security Act. The Department of Healthcare and Family Services shall develop precise standards for payments to reimburse nursing facilities for any utilization of appropriate rehabilitative personnel for the provision of rehabilitative services which is authorized by federal regulations, including reimbursement for services provided by qualified therapists or qualified assistants, and which is in accordance with accepted professional practices. Reimbursement also may be made for utilization of other supportive personnel under appropriate supervision. The Department shall develop enhanced payments to offset the additional costs incurred by a facility serving exceptional need residents and shall allocate at least $4,000,000 of the funds collected from the assessment established by Section 5B-2 of this Code for such payments. For the purpose of this Section, "exceptional needs" means, but need not be limited to, ventilator care and traumatic brain injury care. The enhanced payments for exceptional need residents under this paragraph are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act. Beginning January 1, 2014 the methodologies for reimbursement of nursing facility services as provided under this Section 5-5.4 shall no longer be applicable for services provided on or after January 1, 2014. No payment increase under this Section for the MDS methodology, exceptional care residents, or the socio-development component rate established by Public Act 96-1530 of the 96th General Assembly and funded by the assessment imposed under Section 5B-2 of this Code shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under this Section have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under this Section and the waivers granted under 42 CFR 433.68, all increased payments otherwise due under this Section prior to the date of notification shall be due and payable within 90 days of the date federal approval is received. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect for services delivered on or after August 1, 2019 shall be increased by 3.5% over the rates in effect on June 30, 2019. The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect on the latter of the approval date of the State Plan Amendment for these facilities or the Waiver Amendment for the home and community-based services settings shall include an increase sufficient to provide a $0.26 per hour wage increase to the base wage for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, the rates taking effect for the services delivered on or after July 1, 2020 shall include an increase sufficient to provide a $1.00 per hour wage increase for non-executive staff. For services delivered on or after January 1, 2021, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, shall include an increase sufficient to provide a $0.50 per hour increase for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after July 1, 2021, shall include an increase sufficient to provide a $0.50 per hour increase for aides in the rate methodology. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after January 1, 2022 shall include an increase sufficient to provide a $1.00 per hour increase for aides in the rate methodology. In addition, for residential services delivered on or after January 1, 2022 such rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2023, shall include a $1.00 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases, who work in residential and community day services settings, with at least $0.50 of those funds to be provided as a direct increase to all aide base wages, with the remaining $0.50 to be used flexibly for base wage increases to the rate methodology for aides. In addition, for residential services delivered on or after January 1, 2023 the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2023, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2024 shall include a $2.50 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases and who work in residential and community day services settings. At least $1.25 of the per hour wage increase shall be provided as a direct increase to all aide base wages, and the remaining $1.25 of the per hour wage increase shall be used flexibly for base wage increases to the rate methodology for aides. In addition, for residential services delivered on or after January 1, 2024, the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2024, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of a State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2025 shall include a $1.00 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases and who work in residential and community day services settings, with at least $0.75 of those funds to be provided as a direct increase to all aide base wages and the remaining $0.25 to be used flexibly for base wage increases to the rate methodology for aides. These increases shall not be used by facilities for operational and administrative expenses. In addition, for residential services delivered on or after January 1, 2025, the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2025, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. Notwithstanding any other provision of this Section to the contrary, any regional wage adjuster for facilities located outside of the counties of Cook, DuPage, Kane, Lake, McHenry, and Will shall be no lower than 1.00, and any regional wage adjuster for facilities located within the counties of Cook, DuPage, Kane, Lake, McHenry, and Will shall be no lower than 1.15. (Source: P.A. 102-16, eff. 6-17-21; 102-699, eff. 4-19-22; 103-8, eff. 6-7-23; 103-588, eff. 7-1-24.) |
(305 ILCS 5/5-5.4a)
Sec. 5-5.4a. (Repealed).
(Source: P.A. 96-1530, eff. 2-16-11. Repealed by P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-5.4b)
Sec. 5-5.4b.
Publicly owned or publicly operated nursing facilities.
The
Illinois
Department may by rule establish alternative reimbursement methodologies for
nursing facilities that are owned or operated by a county, a township,
a municipality, a hospital district, or any other local government in
Illinois.
(Source: P.A. 93-20, eff. 6-20-03.)
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(305 ILCS 5/5-5.4c)
Sec. 5-5.4c. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-5.4d) Sec. 5-5.4d. MDS payment methodology; quarterly rate adjustments. (a) On and after July 1, 2009, and until April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be calculated and adjusted quarterly. The Department of Healthcare and Family Services may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare. (b) On April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be frozen to allow the Department of Healthcare and Family Services to develop a rate methodology based on a federally mandated long term care data collection system. The rates in effect prior to and through the quarter ending March 31, 2011, shall continue to be subject to follow-up audits and retroactive rate adjustments pursuant to administrative rules of the Department for reviews of accuracy and resident assessment information. The reimbursement methodology for a Class I Institution for Mental Diseases shall also be frozen pending review of a federally mandated long term care data collection system. (Source: P.A. 96-743, eff. 8-25-09; 96-959, eff. 7-1-10.) |
(305 ILCS 5/5-5.4e) Sec. 5-5.4e. Nursing facilities; ventilator rates. On and after October 1, 2009, the Department of Healthcare and Family Services shall adopt rules to provide medical assistance reimbursement under this Article for the care of persons on ventilators in skilled nursing facilities licensed under the Nursing Home Care Act and certified to participate under the medical assistance program. Accordingly, necessary amendments to the rules implementing the Minimum Data Set (MDS) payment methodology shall also be made to provide a separate per diem ventilator rate based on days of service. The Department may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 96-743, eff. 8-25-09; 97-689, eff. 6-14-12.) |
(305 ILCS 5/5-5.4f) Sec. 5-5.4f. Intermediate care facilities for persons with developmental disabilities quality workforce initiative. (a) Legislative intent. Individuals with developmental disabilities who live in community-based settings rely on direct support staff for a variety of supports and services essential to the ability to reach their full potential. A stable, well-trained direct support workforce is critical to the well-being of these individuals. State and national studies have documented high rates of turnover among direct support workers and confirmed that improvements in wages can help reduce turnover and develop a more stable and committed workforce. This Section would increase the wages and benefits for direct care workers supporting individuals with developmental disabilities and provide accountability by ensuring that additional resources go directly to these workers. (b) Reimbursement. Notwithstanding any provision of Section 5-5.4, in order to attract and retain a stable, qualified, and healthy workforce, beginning July 1, 2010, the Department of Healthcare and Family Services may reimburse an individual intermediate care facility for persons with developmental disabilities for spending incurred to provide improved wages and benefits to its employees serving the individuals residing in the facility. Reimbursement shall be based upon patient days reported in the facility's most recent cost report. Subject to available appropriations, this reimbursement shall be made according to the following criteria: (1) The Department shall reimburse the facility to | ||
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(2) In order to qualify for reimbursement under | ||
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(3) Reimbursement shall be based on the amount of | ||
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(4) Any intermediate care facility for persons with | ||
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(c) Audit. Reimbursement under this Section is subject to audit by the Department and shall be reduced or eliminated in the case of any facility that does not honor its commitment to increase spending to improve the wages and benefits of its employees or that decreases such spending.
(Source: P.A. 99-143, eff. 7-27-15.) |
(305 ILCS 5/5-5.4g)
Sec. 5-5.4g. Minimum Data Set (MDS) Compliance Review; preliminary findings. The Department shall establish by rule a procedure for sharing preliminary Minimum Data Set (MDS) Compliance Review findings with nursing facilities prior to completion of the on-site review. The procedure shall include, but not be limited to, notification to a nursing facility of specific areas of missing documentation required under 89 Ill. Adm. Code 147.75 and the federally mandated resident assessment instrument as specified in 42 CFR 483.20 likely to be determined deficient upon conclusion of the Department's quality assurance review process. Prior to the conclusion of the on-site review, the facility shall be given the opportunity to address the specific areas of missing documentation. A facility disputing any rate change may submit an appeal request pursuant to provisions established at 89 Ill. Adm. Code 140.830. An appeal hearing may be requested if the facility believes that the basis for reducing the facility's MDS rate was in error. The facility may not offer any additional documentation during the appeal hearing, but may identify documentation provided during the on-site review that may support a specific area of documentation deemed deficient by the Department.
(Source: P.A. 96-1317, eff. 7-27-10; 97-333, eff. 8-12-11.)
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(305 ILCS 5/5-5.4h) Sec. 5-5.4h. Medicaid reimbursement for medically complex for the developmentally disabled facilities licensed under the MC/DD Act. (a) Facilities licensed as medically complex for the developmentally disabled facilities that serve severely and chronically ill patients shall have a specific reimbursement system designed to recognize the characteristics and needs of the patients they serve. (b) For dates of services starting July 1, 2013 and until a new reimbursement system is designed, medically complex for the developmentally disabled facilities that meet the following criteria: (1) serve exceptional care patients; and (2) have 30% or more of their patients receiving | ||
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shall receive Medicaid reimbursement on a 30-day expedited schedule.
(c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 through March 31, 2019, medically complex for the developmentally disabled facilities which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669. Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (f) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735. Subject to federal approval, on and after January 1, 2024, each tier rate shall be increased 6% over the amount in effect on the effective date of this amendatory Act of the 103rd General Assembly. Any reimbursement increases applied to the base rate to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to each tier of exceptional care per diem rates for medically complex for the developmentally disabled facilities. (d) For residents on a ventilator pursuant to subsection (c) or subsection (f), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's medical record. (e) For services provided prior to April 1, 2019 and for the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services: (1) Tracheostomy care with dependence on mechanical | ||
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(2) Tracheostomy care requiring suctioning at least | ||
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(3) Total parenteral nutrition or other intravenous | ||
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(4) The following treatment procedures apply to the | ||
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(A) Intermittent suctioning at least every 8 | ||
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(B) Continuous intravenous therapy including | ||
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(C) Peritoneal dialysis treatments requiring at | ||
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(D) Tube feeding via nasogastric or gastrostomy | ||
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(E) Other medical technologies required | ||
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(f) Complex or extensive medical needs for exceptional care reimbursement. The conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) and specified in the most recent manual. Instead of submitting minimum data set assessments to the Department, medically complex for the developmentally disabled facilities must document within each resident's medical record the conditions or services using the minimum data set documentation standards and requirements to qualify for exceptional care reimbursement. (1) Tier 1 reimbursement is for residents who are | ||
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(2) Tier 2 reimbursement is for residents who are | ||
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(3) Tier 3 reimbursement is for residents who are | ||
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(g) For dates of services starting April 1, 2019, reimbursement calculations and direct payment for services provided by medically complex for the developmentally disabled facilities are the responsibility of the Department of Healthcare and Family Services instead of the Department of Human Services. Appropriations for medically complex for the developmentally disabled facilities must be shifted from the Department of Human Services to the Department of Healthcare and Family Services. Nothing in this Section prohibits the Department of Healthcare and Family Services from paying more than the rates specified in this Section. The rates in this Section must be interpreted as a minimum amount. Any reimbursement increases applied to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to medically complex for the developmentally disabled facilities. (h) The Department of Healthcare and Family Services shall pay the rates in effect on March 31, 2019 until the changes made to this Section by this amendatory Act of the 100th General Assembly have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. (i) The Department of Healthcare and Family Services may adopt rules as allowed by the Illinois Administrative Procedure Act to implement this Section; however, the requirements of this Section must be implemented by the Department of Healthcare and Family Services even if the Department of Healthcare and Family Services has not adopted rules by the implementation date of April 1, 2019. (Source: P.A. 103-102, eff. 1-1-24.) |
(305 ILCS 5/5-5.4i) Sec. 5-5.4i. Rates and reimbursements. (a) Within 30 days after July 6, 2017 (the effective date of Public Act 100-23), the Department shall increase rates and reimbursements to fund a minimum of a $0.75 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. (b) Within 30 days after June 4, 2018 (the effective date of Public Act 100-587), the Department shall increase rates and reimbursements to fund a minimum of a $0.50 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. (c) Within 30 days after the effective date of this amendatory Act of the 101st General Assembly, subject to federal approval, the Department shall increase rates and reimbursements in effect on June 30, 2019 for community-based providers for persons with Developmental Disabilities by 3.5%. The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
(Source: P.A. 100-23, eff. 7-6-17; 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.) |
(305 ILCS 5/5-5.4j) Sec. 5-5.4j. ID/DD targeted Medicaid rate enhancement. Within 30 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall increase the Medicaid per diem rate by $21.15 for facilities with more than 16 beds licensed by the Department of Public Health under the ID/DD Community Care Act located in the Department of Public Health's Planning Area 7-B.
(Source: P.A. 100-587, eff. 6-4-18.) |
(305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5) Sec. 5-5.5. Elements of Payment Rate. (a) The Department of Healthcare and Family Services shall develop a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities composed of the following cost elements: (1) Standard Services, with the cost of this | ||
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(2) Resident Services, with the cost of this | ||
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(3) Ancillary Services, with the payment rate being | ||
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(4) Nurse's Aide Training, with the cost of this | ||
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(5) Real Estate Taxes, with the cost of this | ||
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(b) In developing a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities and ICF/DDs, the Department of Healthcare and Family Services shall consider the following cost elements: (1) Reasonable capital cost determined by utilizing | ||
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(2) Profit, with the actual amount being produced and | ||
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(c) The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare. (d) No later than January 1, 2001, the Department of Public Aid shall file with the Joint Committee on Administrative Rules, pursuant to the Illinois Administrative Procedure Act, a proposed rule, or a proposed amendment to an existing rule, regarding payment for appropriate services, including assessment, care planning, discharge planning, and treatment provided by nursing facilities to residents who have a serious mental illness. (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (f) Beginning January 1, 2025, the real estate tax component of the payment rate shall be updated using the most recent property tax bill on file with the Department for facilities licensed under the Nursing Home Care Act and facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013. The per diem rate shall be computed by dividing the real estate tax costs reported in the cost report inflated to the midpoint of the rate year by the total number of patient days reported in the same cost report. Computation of the real estate tax component shall be based on capital days. (Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5.5a) (from Ch. 23, par. 5-5.5a)
Sec. 5-5.5a. Kosher kitchen and food service.
(a) The Department of Healthcare and Family Services may develop in its rate structure for
nursing facilities an accommodation
for fully kosher kitchen and food service operations, rabbinically
approved or certified on an annual basis for a facility in which the only
kitchen or all kitchens are fully kosher (a fully kosher facility).
Beginning in the fiscal year after the fiscal year when this amendatory Act
of 1990 becomes effective, the rate structure may provide for an additional
payment to such facility not to exceed 50 cents per resident per day if 60%
or more of the residents in the facility request kosher foods or food
products prepared in accordance with Jewish religious dietary requirements
for religious purposes in a fully kosher facility. Based upon food cost
reports of the Illinois Department of Agriculture regarding kosher and
non-kosher food available in the various regions of the State, this rate
structure may be periodically adjusted by the Department but may not exceed
the maximum authorized under this subsection (a).
(b) The Department shall by rule determine how a facility with a fully
kosher kitchen and food service may be determined to be eligible and apply
for the rate accommodation specified in subsection (a).
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5.6) (from Ch. 23, par. 5-5.6)
Sec. 5-5.6.
Federal Requirements.
All reimbursement
rates established pursuant to this Act must be consistent
with the criteria for nursing facility reimbursement
established by the Federal government for approval of
matching funds under Title XIX of the Federal
Social Security Act.
(Source: P.A. 80-1142.)
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(305 ILCS 5/5-5.6a)
Sec. 5-5.6a. (Repealed).
(Source: P.A. 85-1440. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5.6b) (from Ch. 23, par. 5-5.6b)
Sec. 5-5.6b. Prohibition against double payment. If any resident of a
nursing facility or ICF/DD is admitted to such
facility on the basis that the charges for such resident's care will be
paid from private funds, and the source of payment for such care thereafter
changes from private funds to payments under this Article, the facility
shall, upon receiving the first such payment under this Article, notify the
Illinois Department of such source of private funds for such recipient and
repay to the source of private funds any amounts received from such source
as payment for care for which payment also was made under this Article.
Private funds shall not include third party resources such as
insurance or Medicare benefits or payments made by responsible relatives.
(Source: P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5.7) (from Ch. 23, par. 5-5.7)
Sec. 5-5.7. Cost reports - audits. The Department of Healthcare and Family Services shall
work with the Department of Public Health to use cost report information
currently being collected under provisions of the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, and the MC/DD Act. The Department of Healthcare and Family Services may, in conjunction with the Department of Public Health,
develop in accordance with generally accepted accounting principles a
uniform chart of accounts which each facility providing services under the
medical assistance program shall adopt, after a reasonable period.
Facilities licensed under the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act
and providers of adult developmental training services certified by the
Department of Human Services pursuant to
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which provide
services to clients eligible for
medical assistance under this Article are responsible for submitting the
required annual cost report to the Department of Healthcare and Family Services.
The Department of Healthcare and Family Services
shall audit the financial and statistical
records of each provider participating in the medical assistance program
as a nursing facility, a specialized mental health rehabilitation facility, or an ICF/DD over a 3 year period,
beginning with the close of the first cost reporting year. Following the
end of this 3-year term, audits of the financial and statistical records
will be performed each year in at least 20% of the facilities participating
in the medical assistance program with at least 10% being selected on a
random sample basis, and the remainder selected on the basis of exceptional
profiles. All audits shall be conducted in accordance with generally accepted
auditing standards.
The Department of Healthcare and Family Services
shall establish prospective payment rates
for categories or levels of services within each licensure class, in order to more appropriately recognize the
individual needs of patients in nursing facilities.
The Department of Healthcare and Family Services
shall provide, during the process of
establishing the payment rate for nursing facility, specialized mental health rehabilitation facility, or ICF/DD
services, or when a substantial change in rates is proposed, an opportunity
for public review and comment on the proposed rates prior to their becoming
effective.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
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(305 ILCS 5/5-5.7a) Sec. 5-5.7a. Pandemic related stability payments for health care providers. Notwithstanding other provisions of law, and in accordance with the Illinois Emergency Management Agency, the Department of Healthcare and Family Services shall develop a process to distribute pandemic related stability payments, from federal sources dedicated for such purposes, to health care providers that are providing care to recipients under the Medical Assistance Program. For provider types serving residents who are recipients of medical assistance under this Code and are funded by other State agencies, the Department will coordinate the distribution process of the pandemic related stability payments. Federal sources dedicated to pandemic related payments include, but are not limited to, funds distributed to the State of Illinois from the Coronavirus Relief Fund pursuant to the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act") and from the Coronavirus State Fiscal Recovery Fund pursuant to Section 9901 of the American Rescue Plan Act of 2021, that are appropriated to the Department during Fiscal Years 2020, 2021, and 2022 for purposes permitted by those federal laws and related federal guidance. (1) Pandemic related stability payments for these | ||
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(2) Payments made from moneys received from the | ||
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(3) All providers receiving pandemic related | ||
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(4) Pandemic related stability payments will be | ||
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(A) the impact of the pandemic on patients | ||
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(B) COVID-19 positivity rates among staff, or | ||
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(C) pandemic related workforce challenges and | ||
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(D) providers with significant reductions in | ||
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(E) pandemic related payments received directly | ||
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(F) current efforts to respond to and provide | ||
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(G) provider needs for capital improvements to | ||
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(5) Pandemic related stability payments made from | ||
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(6) Of the payments provided for by this Section made | ||
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(7) From funds appropriated, directly or indirectly, | ||
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(8) From funds appropriated, directly or indirectly, | ||
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(8.5) From funds appropriated, directly or | ||
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(A) Awards pursuant to this program shall | ||
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(B) Financial assistance under this paragraph | ||
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(i) premium pay for eligible workers, which | ||
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(ii) retention incentives paid to eligible | ||
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(C) Upon receipt of funds, recipients shall | ||
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(D) No portion of these funds shall be spent on | ||
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(E) The Department shall require each recipient | ||
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(9) From funds appropriated, directly or indirectly, | ||
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(A) Payments for making permanent improvements to | ||
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(B) Payments to reimburse facilities licensed | ||
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(i) Awards made pursuant to this program | ||
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(ii) Financial assistance pursuant to this | ||
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(iii) The Department shall require each | ||
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(Source: P.A. 102-16, eff. 6-17-21; 102-687, eff. 12-17-21; 102-699, eff. 4-19-22; 103-8, eff. 6-7-23.) |
(305 ILCS 5/5-5.7b) Sec. 5-5.7b. Pandemic related stability payments to ambulance service providers in response to COVID-19. (a) Definitions. As used in this Section: "Ambulance Services Industry" means the industry that is comprised of "Qualifying Ground Ambulance Service Providers", as defined in this Section. "Qualifying Ground Ambulance Service Provider" means a "vehicle service provider," as that term is defined in Section 3.85 of the Emergency Medical Services (EMS) Systems Act, which operates licensed ambulances for the purpose of providing emergency, non-emergency ambulance services, or both emergency and non-emergency ambulance services. The term "Qualifying Ground Ambulance Service Provider" is limited to ambulance and EMS agencies that are privately held and nonprofit organizations headquartered within the State and licensed by the Department of Public Health as of March 12, 2020. "Eligible worker" means a staff member of a Qualifying Ground Ambulance Service Provider engaged in "essential work", as defined by Section 9901 of the ARPA and related federal guidance, and (1) whose total pay is below 150% of the average annual wage for all occupations in the worker's county of residence, as defined by the BLS Occupational Employment and Wage Statistics or (2) is not exempt from the federal Fair Labor Standards Act overtime provisions. (b) Purpose. The Department may receive federal funds under the authority of legislation passed in response to the Coronavirus epidemic, including, but not limited to, the American Rescue Plan Act of 2021, P.L. 117-2 (the "ARPA"). Upon receipt or availability of such State or federal funds, and subject to appropriations for their use, the Department shall establish and administer programs for purposes allowable under Section 9901 of the ARPA to provide financial assistance to Qualifying Ground Ambulance Service Providers for premium pay for eligible workers, to provide reimbursement for eligible expenditures, and to provide support following the negative economic impact of the COVID-19 public health emergency on the Ambulance Services Industry. Financial assistance may include, but is not limited to, grants, expense reimbursements, or subsidies. (b-1) By December 31, 2022, the Department shall obtain appropriate documentation from Qualifying Ground Ambulance Service Providers to ascertain an accurate count of the number of licensed vehicles available to serve enrollees in the State's medical assistance programs, which shall be known as the "total eligible vehicles". By February 28, 2023, Qualifying Ground Ambulance Service Providers shall be initially notified of their eligible award, which shall be the product of (i) the total amount of funds allocated under this Section and (ii) a quotient, the numerator of which is the number of licensed ground ambulance vehicles of an individual Qualifying Ground Ambulance Service Provider and the denominator of which is the total eligible vehicles. After March 31, 2024, any unobligated funds shall be reallocated pro rata to the remaining Qualifying Ground Ambulance Service Providers that are able to prove up eligible expenses in excess of their initial award amount until all such appropriated funds are exhausted. Providers shall indicate to the Department what portion of their award they wish to allocate under the purposes outlined under paragraphs (d), (e), or (f), if applicable, of this Section. (c) Non-Emergency Service Certification. To be eligible for funding under this Section, a Qualifying Ground Ambulance Service Provider that provides non-emergency services to institutional residents must certify whether or not it is able to provide non-emergency ambulance services to individuals enrolled in the State's Medical Assistance Program and residing in non-institutional settings for at least one year following the receipt of funding pursuant to this amendatory Act of the 102nd General Assembly. Certification indicating that a provider has such an ability does not mean that a provider is required to accept any or all requested transports. (d) Premium Pay Initiative. Subject to paragraph (c) of this Section, the Department shall establish a Premium Pay Initiative to distribute awards to each Qualifying Ground Ambulance Service Provider for the purpose of providing premium pay to eligible workers. (1) Financial assistance pursuant to this paragraph | ||
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(2) The financial assistance awarded shall only be | ||
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(3) Upon receipt of funds, the Qualifying Ground | ||
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(4) No portion of these funds shall be spent on | ||
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(5) These funds shall not be used to make | ||
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(6) The Department shall require each Qualifying | ||
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(e) COVID-19 Response Support Initiative. Subject to paragraph (c) of this Section and based on an application filed by a Qualifying Ground Ambulance Service Provider, the Department shall establish the Ground Ambulance COVID-19 Response Support Initiative. The purpose of the award shall be to reimburse Qualifying Ground Ambulance Service Providers for eligible expenses under Section 9901 of the ARPA related to the public health impacts of the COVID-19 public health emergency, including, but not limited to: (i) costs incurred due to the COVID-19 public health emergency; (ii) costs related to vaccination programs, including vaccine incentives; (iii) costs related to COVID-19 testing; (iv) costs related to COVID-19 prevention and treatment equipment; (v) expenses for medical supplies; (vi) expenses for personal protective equipment; (vii) costs related to isolation and quarantine; (viii) costs for ventilation system installation and improvement; (ix) costs related to other emergency response equipment, such as ground ambulances, ventilators, cardiac monitoring equipment, defibrillation equipment, pacing equipment, ambulance stretchers, and radio equipment; and (x) other emergency medical response expenses. (1) The award shall be for eligible obligated | ||
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(2) Funds awarded under this paragraph (e) shall | ||
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(3) The Department shall require each Qualifying | ||
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(f) Ambulance Industry Recovery Program. If the Department designates the Ambulance Services Industry as an "impacted industry", as defined by the ARPA and related federal guidance, the Department shall establish the Ambulance Industry Recovery Grant Program, to provide aid to Qualifying Ground Ambulance Service Providers that experienced staffing losses due to the COVID-19 public health emergency. (1) Funds awarded under this paragraph (f) shall | ||
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(2) Each Qualifying Ground Ambulance Service | ||
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(3) The Department shall require each Qualifying | ||
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(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.) |
(305 ILCS 5/5-5.8) (from Ch. 23, par. 5-5.8)
Sec. 5-5.8. Report on nursing home reimbursement. The Illinois
Department shall report annually to the General Assembly, no later than the
first Monday in April of 1982, and each year thereafter, in regard to:
(a) the rate structure used by the Illinois | ||
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(b) changes in the rate structure for reimbursing | ||
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(c) the administrative and program costs of | ||
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(d) the availability of beds in nursing facilities | ||
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(e) the number of closings of nursing facilities, and | ||
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(f) for years beginning 2025 and thereafter, drawing | ||
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The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report
as required by Section 3.1 of the General Assembly Organization Act, and filing such
additional copies with the State Government Report Distribution Center for
the General Assembly as is required under paragraph (t) of Section 7 of the
State Library Act.
(Source: P.A. 102-1035, eff. 5-31-22.)
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(305 ILCS 5/5-5.08a) Sec. 5-5.08a. Renal dialysis; add-on payments for home dialysis providers in skilled nursing facilities. (a) Findings. The General Assembly finds the following: (1) Home dialysis services provided on-site at | ||
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(2) Home dialysis for nursing home residents provides | ||
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(3) On-site home dialysis in nursing homes is | ||
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(b) Subject to federal approval, for dates of service beginning on and after January 1, 2025, for home renal dialysis provided to residents of skilled nursing facilities, the Department shall reimburse a per-claim add-on payment to certified home dialysis providers in accordance with this Section. Certified home dialysis providers providing dialysis services within a skilled nursing facility shall receive a per-claim add-on payment of $95 per treatment. As used in this Section, "certified home dialysis provider" means an end-stage renal disease facility that (i) provides dialysis treatment or dialysis training to caregivers or individuals with end-stage renal disease and (ii) has been approved to provide dialysis home training support services by the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5.8a)
Sec. 5-5.8a. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 96-1123, eff. 1-1-11.)
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(305 ILCS 5/5-5.8b) (from Ch. 23, par. 5-5.8b)
Sec. 5-5.8b. Payment to Campus Facilities. There is hereby established
a separate payment category for campus facilities. A "campus facility" is
defined as an entity which consists of a long term care facility (or group
of facilities if the facilities are on the same contiguous parcel of real
estate) which meets all of the following criteria as of May 1,
1987: the
entity provides care for both children and adults; residents of the entity
reside in three or more separate buildings with congregate and small group
living arrangements on a single campus; the entity provides three or more
separate licensed levels of care; the entity (or a part of the entity) is
enrolled with the Department of Healthcare and Family Services as a provider of long term care
services and receives payments from that Department; the
entity (or a part of the entity) receives funding from the Department of
Human
Services; and the entity (or a part of
the entity) holds a current license as a child care institution issued by
the Department of Children and Family Services.
The Department of Healthcare and Family Services, the Department of Human Services, and the Department of Children and Family
Services shall develop jointly a rate methodology or methodologies for
campus facilities. Such methodology or methodologies may establish a
single rate to be paid by all the agencies, or a separate rate to be paid
by each agency, or separate components to be paid to
different parts of the campus facility. All campus facilities shall
receive the same rate of payment for similar services. Any methodology
developed pursuant to this section shall take into account the actual costs
to the facility of providing services to residents, and shall be adequate
to reimburse the allowable costs of a campus facility which is economically
and efficiently operated. Any methodology shall be established on the
basis of historical, financial, and statistical data submitted by campus
facilities, and shall take into account the actual costs incurred by campus
facilities in providing services, and in meeting licensing and
certification standards imposed and prescribed by the State of Illinois,
any of its political subdivisions or municipalities and by the United
States Department of Health and Human Services. Rates may be established
on a prospective or retrospective basis. Any methodology shall provide
reimbursement for appropriate payment elements, including the following:
standard services, patient services, real estate taxes, and capital costs.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-5.09) Sec. 5-5.09. Mental health professionals; veterans. (a) The General Assembly is proud of and grateful to members of all branches of the United States Armed Forces. The General Assembly recognizes that returning veterans may have unique and specific needs that are better understood and addressed by persons with military exposure. The Department of Healthcare and Family Services shall seek federal approval of an amendment to the Illinois Title XIX State Plan for the purpose of allowing a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional. (b) Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department of Healthcare and Family Services, in collaboration with all necessary partners including the Department of Human Services, shall adopt within 180 days after the date upon which federal approval is received any necessary rules that would allow a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional for purposes of programs authorized or funded by the Department of Healthcare and Family Services under the standards of practice as authorized by the Department.
(Source: P.A. 100-908, eff. 1-1-19.) |
(305 ILCS 5/5-5.10) Sec. 5-5.10. Value-based purchasing. (a) The Department of Healthcare and Family Services, and, as appropriate, divisions within the Department of Human Services, shall confer with stakeholders to discuss development of alternative value-based payment models that move away from fee-for-service and reward health outcomes and improved quality and provide flexibility in how providers meet the needs of the individuals they serve. Stakeholders include providers, managed care organizations, and community-based and advocacy organizations. The approaches explored may be different for different types of services. (b) The Department of Healthcare and Family Services and the Department of Human Services shall initiate discussions with mental health providers, substance abuse providers, managed care organizations, advocacy groups for individuals with behavioral health issues, and others, as appropriate, no later than July 1, 2019. A model for value-based purchasing for behavioral health providers shall be presented to the General Assembly by January 31, 2020. In developing this model, the Department of Healthcare and Family Services shall develop projections of the funding necessary for the model.
(Source: P.A. 101-209, eff. 8-5-19.) |
(305 ILCS 5/5-5.11)
Sec. 5-5.11. (Repealed).
(Source: P.A. 83-748. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for reimbursement under this
Article for prescription drugs provided to a recipient of aid under this
Article shall include the name of the prescriber or an acceptable
identification number as established by the Department.
(b) Pharmacies providing prescription drugs under
this Article shall be reimbursed at a rate which shall include
a professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the prescription
drug dispensed. The Illinois Department shall update its
information on the acquisition costs of all prescription drugs
no less frequently than every 30 days. However, the Illinois
Department may set the rate of reimbursement for the acquisition
cost, by rule, at a percentage of the current average wholesale
acquisition cost.
(c) (Blank).
(d) The Department shall review utilization of narcotic medications in the medical assistance program and impose utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be on a prior approval list, the Department shall include as part of the analysis for this determination, the degree to which a drug may affect individuals in different ways based on factors including the gender of the person taking the medication. (f) The Department shall cooperate with the Department of Public Health and the Department of Human Services Division of Mental Health in identifying psychotropic medications that, when given in a particular form, manner, duration, or frequency (including "as needed") in a dosage, or in conjunction with other psychotropic medications to a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, may constitute a chemical restraint or an "unnecessary drug" as defined by the Nursing Home Care Act or Titles XVIII and XIX of the Social Security Act and the implementing rules and regulations. The Department shall require prior approval for any such medication prescribed for a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, that appears to be a chemical restraint or an unnecessary drug. The Department shall consult with the Department of Human Services Division of Mental Health in developing a protocol and criteria for deciding whether to grant such prior approval. (g) The Department may by rule provide for reimbursement of the dispensing of a 90-day supply of a generic or brand name, non-narcotic maintenance medication in circumstances where it is cost effective. (g-5) On and after July 1, 2012, the Department may require the dispensing of drugs to nursing home residents be in a 7-day supply or other amount less than a 31-day supply. The Department shall pay only one dispensing fee per 31-day supply. (h) Effective July 1, 2011, the Department shall discontinue coverage of select over-the-counter drugs, including analgesics and cough and cold and allergy medications. (h-5) On and after July 1, 2012, the Department shall impose utilization controls, including, but not limited to, prior approval on specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. The Department may adjust payment methodologies for non-pharmacy billed drugs in order to incentivize the selection of lower-cost drugs. For drugs for the treatment of AIDS, the Department shall take into consideration the potential for non-adherence by certain populations, and shall develop protocols with organizations or providers primarily serving those with HIV/AIDS, as long as such measures intend to maintain cost neutrality with other utilization management controls such as prior approval.
For hemophilia, the Department shall develop a program of utilization review and control which may include, in the discretion of the Department, prior approvals. The Department may impose special standards on providers that dispense blood factors which shall include, in the discretion of the Department, staff training and education; patient outreach and education; case management; in-home patient assessments; assay management; maintenance of stock; emergency dispensing timeframes; data collection and reporting; dispensing of supplies related to blood factor infusions; cold chain management and packaging practices; care coordination; product recalls; and emergency clinical consultation. The Department may require patients to receive a comprehensive examination annually at an appropriate provider in order to be eligible to continue to receive blood factor. (i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (j) On and after July 1, 2012, the Department shall impose limitations on prescription drugs such that the Department shall not provide reimbursement for more than 4 prescriptions, including 3 brand name prescriptions, for distinct drugs in a 30-day period, unless prior approval is received for all prescriptions in excess of the 4-prescription limit. Drugs in the following therapeutic classes shall not be subject to prior approval as a result of the 4-prescription limit: immunosuppressant drugs, oncolytic drugs, anti-retroviral drugs, and, on or after July 1, 2014, antipsychotic drugs. On or after July 1, 2014, the Department may exempt children with complex medical needs enrolled in a care coordination entity contracted with the Department to solely coordinate care for such children, if the Department determines that the entity has a comprehensive drug reconciliation program. (k) No medication therapy management program implemented by the Department shall be contrary to the provisions of the Pharmacy Practice Act. (l) Any provider enrolled with the Department that bills the Department for outpatient drugs and is eligible to enroll in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act shall enroll in that program. No entity participating in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act may exclude fee-for-service Medicaid from their participation in that program, however, entities defined in Section 1905(l)(2)(B) of the Social Security Act are excluded from this requirement. This subsection does not apply to outpatient drugs billed to Medicaid managed care organizations. (Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
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(305 ILCS 5/5-5.12a)
Sec. 5-5.12a.
Title XIX waiver; pharmacy assistance program.
The
Illinois Department may seek a waiver of otherwise applicable requirements
of Title XIX of the federal Social Security Act in order to claim federal
financial participation for a pharmacy assistance program for persons aged
65 and over with income levels at or less than 250% of the federal poverty
level. The Illinois Department may provide by rule for all other requirements
of the program, including cost sharing, as permitted by an approved waiver and
without regard to any provision of this Code to the contrary. The benefits may
be no more restrictive than the Pharmacy Assistance Program in effect on May
31, 2001. Benefits provided under the waiver are subject to appropriation.
The Illinois Department may not implement the waiver until cost neutrality is
demonstrated for the State relative to the final Pharmacy Assistance Program
appropriation for the fiscal year beginning July 1, 2001. Implementation of
the waiver shall terminate on June 30, 2007.
(Source: P.A. 92-10, eff. 6-11-01.)
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(305 ILCS 5/5-5.12b) Sec. 5-5.12b. Critical access care pharmacy program. (a) As used in this Section: "Critical access care pharmacy" means an Illinois-based brick and mortar pharmacy that is located in a county with fewer than 50,000 residents and that owns fewer than 10 pharmacies. "Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018. "Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. (b) Subject to appropriations, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois. (c) The critical access care pharmacy program shall not exceed $10,000,000 annually and individual payment amounts per prescription shall not exceed the dispensing rate that the Department would have reimbursed under the Medical Assistance Program as of April 1, 2018. (d) Quarterly, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018. (e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018. (f) The Department may adopt rules permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy is located in a county with a population of less than 50,000.
(Source: P.A. 100-587, eff. 6-4-18.) |
(305 ILCS 5/5-5.12c) Sec. 5-5.12c. Managed care organization uniform electronic prior authorization form; prescription benefits. (a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured. (b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits. (c) On or before July 1, 2020, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits. (d) The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting. (e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following: (1) existing prior authorization forms established by | ||
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(2) national standards pertaining to electronic prior | ||
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(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, a managed care organization fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours, then the prior authorization request shall be deemed to have been granted.
(Source: P.A. 101-463, eff. 1-1-20.) |
(305 ILCS 5/5-5.12d) Sec. 5-5.12d. Coverage for patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis provided by a pharmacist. (a) Subject to approval by the federal Centers for Medicare and Medicaid Services, the medical assistance program, including both the fee-for-service and managed care medical assistance programs established under this Article, shall cover patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation. (b) The Department shall establish a fee schedule for patient care services provided by a pharmacist under Sections 43 and 43.5 of the Pharmacy Practice Act and shall be covered and reimbursed at no less than 85% of the rate that the services are reimbursed when provided by a physician. (c) The rate of reimbursement for patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation shall be at 85% of the fee schedule for physician services by the medical assistance program. (d) A pharmacist must be enrolled in the medical assistance program as an ordering and referring provider prior to providing patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation that is submitted by a pharmacy or pharmacist provider for reimbursement pursuant to this Section. (e) The Department shall apply for any necessary federal waivers or approvals to implement this Section by January 1, 2023. (f) This Section does not restrict or prohibit any services currently provided by pharmacists as authorized by law, including, but not limited to, pharmacist services provided under this Code or authorized under the Illinois Title XIX State Plan. (g) The Department shall submit to the Joint Committee on Administrative Rules administrative rules for this Section as soon as practicable but no later than 6 months after federal approval is received.
(Source: P.A. 102-103, eff. 1-1-22; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.) |
(305 ILCS 5/5-5.12e)
Sec. 5-5.12e. Managed care organization prior authorization of health care services. (a) As used in this Section, "health care service" has the meaning given to that term in the Prior Authorization Reform Act. (b) Notwithstanding any other provision of law to the contrary, all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act.
(Source: P.A. 102-409, eff. 1-1-22; 102-813, eff. 5-13-22.)
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(305 ILCS 5/5-5.12f) Sec. 5-5.12f. Prescription drugs for mental illness; no utilization or prior approval mandates. (a) Notwithstanding any other provision of this Code to the contrary, except as otherwise provided in subsection (b), for the purpose of removing barriers to the timely treatment of serious mental illnesses, prior authorization mandates and utilization management controls shall not be imposed under the fee-for-service and managed care medical assistance programs on any FDA-approved prescription drug that is recognized by a generally accepted standard medical reference as effective in the treatment of conditions specified in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association if a preferred or non-preferred drug is prescribed to an adult patient to treat serious mental illness and one of the following applies: (1) the patient has changed providers, including, but | ||
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(2) the patient has changed insurance coverage and is | ||
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(3) subject to federal law on maximum dosage limits | ||
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(b) The following safety edits shall be permitted for prescription drugs covered under this Section: (1) clinically appropriate drug utilization review | ||
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(2) generic drug substitution if a generic drug is | ||
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(3) any utilization management control that is | ||
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(c) As used in this Section, "serious mental illness" means any one or more of the following diagnoses and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes listed by the Department of Human Services' Division of Mental Health, as amended, on its official website: (1) Delusional Disorder (F22) (2) Brief Psychotic Disorder (F23) (3) Schizophreniform Disorder (F20.81) (4) Schizophrenia (F20.9) (5) Schizoaffective Disorder (F25.x) (6) Catatonia Associated with Another Mental Disorder | ||
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(7) Other Specified Schizophrenia Spectrum and Other | ||
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(8) Unspecified Schizophrenia Spectrum and Other | ||
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(9) Bipolar I Disorder (F31.xx) (10) Bipolar II Disorder (F31.81) (11) Cyclothymic Disorder (F34.0) (12) Unspecified Bipolar and Related Disorder (F31.9) (13) Disruptive Mood Dysregulation Disorder (F34.8) (14) Major Depressive Disorder Single episode (F32.xx) (15) Major Depressive Disorder, Recurrent episode | ||
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(16) Obsessive-Compulsive Disorder (F42) (17) Posttraumatic Stress Disorder (F43.10) (18) Anorexia Nervosa (F50.0x) (19) Bulimia Nervosa (F50.2) (20) Postpartum Depression (F53.0) (21) Puerperal Psychosis (F53.1) (22) Factitious Disorder Imposed on Another (F68.A) (d) Notwithstanding any other provision of law, nothing in this Section shall not be construed to conflict with Section 1927(a)(1) and (b)(1)(A) of the federal Social Security Act and any implementing regulations and agreements.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5.13) (from Ch. 23, par. 5-5.13)
Sec. 5-5.13.
The Illinois Department shall establish procedures for the
expedited review, for purposes of inclusion in the Illinois Public Aid
formulary, of any drug for the treatment of acquired immunodeficiency syndrome
(AIDS) which the federal Food and Drug Administration has indicated is subject
to a treatment investigational new drug application.
(Source: P.A. 88-85.)
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(305 ILCS 5/5-5.14)
Sec. 5-5.14.
(Repealed).
(Source: Repealed by P.A. 88-85.)
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(305 ILCS 5/5-5.14.5) Sec. 5-5.14.5. Treatment; substance use disorder and mental health. The Department shall consult with stakeholders and General Assembly members for input on a plan to develop enhanced Medicaid rates for substance use disorder treatment and mental health treatment in underserved communities. The Department shall present the plan to General Assembly members within 3 months of the effective date of this amendatory Act of the 101st General Assembly, which will specifically address ensuring access to treatment in provider deserts. Within 4 months of the effective date of this amendatory Act of the 101st General Assembly, the Department shall submit a State plan amendment to create medical assistance enhanced rates to enhance access to those to community mental health services and substance abuse services for underserved communities.
Subject to federal approval, the Department shall create medical assistance enhanced rates for community mental health services and substance abuse providers for underserved communities to enhance access to those communities.
(Source: P.A. 101-10, eff. 6-5-19.) |
(305 ILCS 5/5-5.15)
Sec. 5-5.15. (Repealed).
(Source: P.A. 83-1509. Repealed by P.A. 96-1501, eff. 1-25-11.)
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(305 ILCS 5/5-5.16) (from Ch. 23, par. 5-5.16)
Sec. 5-5.16.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
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(305 ILCS 5/5-5.17) (from Ch. 23, par. 5-5.17)
Sec. 5-5.17. Separate reimbursement rate. The Illinois Department may
by rule establish a separate reimbursement rate to be paid to long term
care facilities for adult developmental training services as defined in
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which are provided to
residents of such facilities who have intellectual disabilities and who receive aid under this Article. Any such
reimbursement shall be based upon cost reports submitted by the providers
of such services and shall be paid by the long term care facility to the
provider within such time as the Illinois Department shall prescribe by
rule, but in no case less than 3 business days after receipt of the
reimbursement by such facility from the Illinois Department. The Illinois
Department may impose a penalty upon a facility which does not make payment
to the provider of adult developmental training services within the time so
prescribed, up to the amount of payment not made to the provider.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5-5.18)
Sec. 5-5.18.
Diagnosis accompanying request for reimbursement.
Every
request submitted by a physician for reimbursement under this Article for
services provided to a recipient of aid under this Article shall include the
physician's diagnosis of the recipient's illness or other condition requiring
those services. The diagnosis shall be either written out or expressed in a
code approved by the Illinois Department.
(Source: P.A. 88-554, eff. 7-26-94.)
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(305 ILCS 5/5-5.19)
Sec. 5-5.19.
Reimbursement request records.
The Illinois Department shall
file all requests for reimbursement for medical services provided under this
Article
according to both (i) the name of the service provider and (ii) the name of the
recipient of aid under this Article to whom the medical services were
provided.
(Source: P.A. 88-554, eff. 7-26-94.)
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(305 ILCS 5/5-5.20)
Sec. 5-5.20. Clinic payments. For services provided by federally
qualified health centers as defined in Section 1905 (l)(2)(B) of the federal
Social Security Act, on or after April 1, 1989, and as long as required by
federal law, the Illinois Department shall
reimburse those health centers for those services according to a prospective
cost-reimbursement methodology.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-5.21)
Sec. 5-5.21. (Repealed).
(Source: P.A. 89-415, eff. 1-1-96. Repealed by P.A. 96-1530, eff. 2-16-11.)
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(305 ILCS 5/5-5.22)
Sec. 5-5.22. (Repealed).
(Source: P.A. 92-725, eff. 7-25-02. Repealed by P.A. 94-838, eff. 6-6-06.)
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(305 ILCS 5/5-5.23)
Sec. 5-5.23. Children's mental health services.
(a) The Department of Healthcare and Family Services, by rule, shall require the screening and
assessment of
a child prior to any Medicaid-funded admission to an inpatient hospital for
psychiatric
services to be funded by Medicaid. The screening and assessment shall include a
determination of the appropriateness and availability of out-patient support
services
for necessary treatment. The Department, by rule, shall establish methods and
standards of payment for the screening, assessment, and necessary alternative
support
services.
(b) The Department of Healthcare and Family Services, to the extent allowable under federal law,
shall secure federal financial participation for Individual Care Grant
expenditures made
by the Department of Healthcare and Family Services for the Medicaid optional service
authorized under
Section 1905(h) of the federal Social Security Act, pursuant to the provisions
of Section
7.1 of the Mental Health and Developmental Disabilities Administrative Act. The
Department of Healthcare and Family Services may exercise the
authority under this Section as is necessary to administer
Individual Care Grants as authorized under Section 7.1 of the
Mental Health and Developmental Disabilities Administrative
Act.
(c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family
Services and the Division of Mental Health of the Department of
Human Services to implement subsections (a) and (b).
(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (e) All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly. (1) Each act done by the Department of Healthcare and | ||
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(2) Any rules of the Department of Human Services | ||
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(3) All unexpended appropriations and balances and | ||
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(4) Existing personnel and positions of the | ||
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(5) All books, records, papers, documents, property | ||
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(6) Whenever reports or notices are now required to | ||
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(7) This amendatory Act of the 99th General Assembly | ||
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(f) (Blank). (g) Family Support Program. The Department of Healthcare and Family Services shall restructure the Family Support Program, formerly known as the Individual Care Grant program, to enable early treatment of youth, emerging adults, and transition-age adults with a serious mental illness or serious emotional disturbance. (1) As used in this subsection and in subsections (h) | ||
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(A) "Youth" means a person under the age of 18. (B) "Emerging adult" means a person who is 18 | ||
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(C) "Transition-age adult" means a person who is | ||
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(2) The Department shall amend 89 Ill. Adm. Code 139 | ||
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(3) Implementation of any amended requirements shall | ||
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(4) To align the Family Support Program with the | ||
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(5) The Family Support Program shall align with the | ||
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(A) Treatment and support services shall be based | ||
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(B) Strong interagency collaboration between all | ||
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(C) Individualized, strengths-based practices and | ||
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(D) For a youth, full participation of the parent | ||
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(h) Eligibility for the Family Support Program. Eligibility criteria established under 89 Ill.
Adm. Code 139 for the Family Support Program shall include the following: (1) Individuals applying to the program must be under | ||
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(2) Requirements for parental or legal guardian | ||
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(3) Youth, emerging adults, and transition-age adults | ||
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(4) School participation for emerging adults applying | ||
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(5) School participation is not applicable to | ||
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(i) Notification of Family Support Program and Specialized Family Support Program services. (1) Within 12 months after the effective date of this | ||
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(2) Upon a youth's, emerging adult's or | ||
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(3) Psychiatric lockout as last resort. (A) Prior to referring any youth to the | ||
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(B) No state agency or hospital shall coach a | ||
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(4) Development of new Family Support Program | ||
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(A) Development of specialized therapeutic | ||
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(B) Using the Department of Children and Family | ||
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(C) Development of an age-appropriate therapeutic | ||
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(j) Workgroup to develop a plan for improving access to substance use treatment. The Department of Healthcare and Family Services and the Department of Human Services' Division of Substance Use Prevention and Recovery shall co-lead a working group that includes Family Support Program providers, family support organizations, and other stakeholders over a 12-month period beginning in the first quarter of calendar year 2020 to develop a plan for increasing access to substance use treatment services for youth, emerging adults, and transition-age adults who are eligible for Family Support Program services. (k) Appropriation. Implementation of this Section shall be limited by the State's annual appropriation to the Family Support Program. Spending within the Family Support Program appropriation shall be further limited for the new Family Support Program services to be developed accordingly: (1) Targeted use of specialized therapeutic | ||
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(2) Targeted use of residential treatment model | ||
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(l) Exhausting third party insurance coverage first. (A) A parent, legal guardian, emerging adult, or | ||
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(B) The Department of Healthcare and Family Services | ||
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(C) If private or public insurance coverage does not | ||
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(m) Service authorization. A youth, emerging adult, or transition-age adult enrolled in the Family Support Program or the Specialized Family Support Program shall be eligible to receive a mental health treatment service covered by the applicable program if the medical necessity criteria established by the Department of Healthcare and Family Services are met. (n) Streamlined application. The Department of Healthcare and Family Services shall revise the Family Support Program applications and the application process to reflect the changes made to this Section by this amendatory Act of the 101st General Assembly within 8 months after the adoption of any amendments to 89 Ill.
Adm. Code 139. (o) Study of reimbursement policies during planned and unplanned absences of youth and emerging adults in Family Support Program residential treatment settings. The Department of Healthcare and Family Services shall undertake a study of those standards of the Department of Children and Family Services and other states for reimbursement of residential treatment during planned and unplanned absences to determine if reimbursing residential providers for such unplanned absences positively impacts the availability of residential treatment for youth and emerging adults. The Department of Healthcare and Family Services shall begin the study on July 1, 2019 and shall report its findings and the results of the study to the General Assembly, along with any recommendations for or against adopting a similar policy, by December 31, 2020. (p) Public awareness and educational campaign for all relevant providers. The Department of Healthcare and Family Services shall engage in a public awareness campaign to educate hospitals with psychiatric units, crisis response providers such as Screening, Assessment and Support Services providers and Comprehensive Community Based Youth Services agencies, schools, and other community institutions and providers across Illinois on the changes made by this amendatory Act of the 101st General Assembly to the Family Support Program. The Department of Healthcare and Family Services shall produce written materials geared for the appropriate target audience, develop webinars, and conduct outreach visits over a 12-month period beginning after implementation of the changes made to this Section by this amendatory Act of the 101st General Assembly. (q) Maximizing federal matching funds for the Family Support Program and the Specialized Family Support Program. The Department of Healthcare and Family Services, as the sole Medicaid State agency, shall seek approval from the federal Centers for Medicare and Medicaid Services within 12 months after the effective date of this amendatory Act of the 101st General Assembly to draw additional federal Medicaid matching funds for individuals served under the Family Support Program or the Specialized Family Support Program who are not covered by the Department's medical assistance programs. The Department of Children and Family Services, as the State agency responsible for administering federal funds pursuant to Title IV-E of the Social Security Act, shall submit a State Plan to the federal government within 12 months after the effective date of this amendatory Act of the 101st General Assembly to maximize the use of federal Title IV-E prevention funds through the federal Family First Prevention Services Act, to provide mental health and substance use disorder treatment services and supports, including, but not limited to, the provision of short-term crisis and transition beds post-hospitalization for youth who are at imminent risk of entering Illinois' youth welfare system solely due to the inability to access mental health or substance use treatment services. (r) Outcomes and data reported annually to the General Assembly. Beginning in 2021, the Department of Healthcare and Family Services shall submit an annual report to the General Assembly that includes the following information with respect to the time period covered by the report: (1) The number and ages of youth, emerging adults, | ||
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(2) The number and ages of youth, emerging adults, | ||
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(3) The number and ages of youth, emerging adults, | ||
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(s) Rulemaking authority. Unless a timeline is otherwise specified in a subsection, if amendments to 89 Ill. Adm. Code 139 are needed for implementation of this Section, such amendments shall be filed by the Department of Healthcare and Family Services within one year after the effective date of this amendatory Act of the 101st General Assembly.(Source: P.A. 101-461, eff. 1-1-20; 101-616, eff. 12-20-19.)
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(305 ILCS 5/5-5.24)
Sec. 5-5.24. Prenatal and perinatal care. (a) The Department of
Healthcare and Family Services may provide reimbursement under this Article for all prenatal and
perinatal health care services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal intensive care hospital
services, and promoting perinatal and maternal health. These services may include
comprehensive risk assessments for pregnant individuals, individuals with infants, and
infants, lactation counseling, nutrition counseling, childbirth support,
psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and
other support
services
that have been proven to improve birth and maternal health outcomes.
The Department
shall
maximize the use of preventive prenatal and perinatal health care services
consistent with
federal statutes, rules, and regulations.
The Department of Public Aid (now Department of Healthcare and Family Services)
shall develop a plan for prenatal and perinatal preventive
health care and
shall present the plan to the General Assembly by January 1, 2004.
On or before January 1, 2006 and
every 2 years
thereafter, the Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services reimbursed under
this Section
in preventing low-birthweight infants and reducing the need for neonatal
intensive care
hospital services. Each such report shall include an evaluation of how the
ratio of
expenditures for treating
low-birthweight infants compared with the investment in promoting healthy
births and
infants in local community areas throughout Illinois relates to healthy infant
development
in those areas.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (b)(1) As used in this subsection: "Affiliated provider" means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization. "Non-affiliated provider" means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO. "Preventive prenatal and perinatal health care services" means services described in subsection (a) including the following non-emergent diagnostic and ancillary services: (i) Diagnostic labs and imaging, including level II | ||
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(ii) RhoGAM injections. (iii) Injectable 17-alpha-hydroxyprogesterone | ||
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(iv) Intrapartum (labor and delivery) services. (v) Any other outpatient or inpatient service | ||
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(2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, including all policy adjusters, including, but not limited to, Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates, unless a different rate was agreed upon by the health plan and the non-affiliated provider. (3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and: (A) the non-affiliated provider is a perinatal | ||
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(B) the health plan has terminated a contract with | ||
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(i) an institutional provider has repeatedly | ||
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(ii) the provider's conduct adversely and | ||
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(iii) the provider's conduct constitutes fraud, | ||
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(iv) the provider's conduct violates the code of | ||
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(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)
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(305 ILCS 5/5-5.24a) (Text of Section from P.A. 103-593) Sec. 5-5.24a. Remote ultrasounds and remote fetal nonstress tests; reimbursement. (a) Subject to federal approval, for dates of service beginning on and after January 1, 2025, the Department shall reimburse for remote ultrasound procedures and remote fetal nonstress tests when the patient is in a residence or other off-site location from the patient's provider and the same standard of care is met as would be present during an in-person visit. (b) Remote ultrasounds and remote fetal nonstress tests are only eligible for reimbursement when the provider uses digital technology: (1) to collect medical and other forms of health data | ||
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(2) that is compliant with the federal Health | ||
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(3) that is approved by the U.S. Food and Drug | ||
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(c) A fetal nonstress test is only eligible for reimbursement with a place of service modifier for at-home monitoring with remote monitoring solutions that are cleared by the U.S. Food and Drug Administration for on-label use for monitoring fetal heart rate, maternal heart rate, and uterine activity. (d) The Department shall issue guidance to implement the provisions of this Section.(Source: P.A. 103-593, eff. 6-7-24.) (Text of Section from P.A. 103-870) (This Section may contain text from a Public Act with a delayed effective date) Sec. 5-5.24a. Coverage for at-home pregnancy tests. Beginning January 1, 2025, the medical assistance program shall provide coverage for at-home, urine-based pregnancy tests that are ordered directly by a clinician or furnished through a standing order for patient use, regardless of whether the tests are otherwise available over the counter. The coverage required under this Section is limited to a multipack, as defined by the Department, of at-home, urine-based pregnancy tests every 30 days.(Source: P.A. 103-870, eff. 1-1-25.) |
(305 ILCS 5/5-5.25) Sec. 5-5.25. Access to behavioral health, medical, and epilepsy treatment services. (a) The General Assembly finds that providing access to behavioral health, medical, and epilepsy treatment services in a timely manner will improve the quality of life for persons suffering from illness and will contain health care costs by avoiding the need for more costly inpatient hospitalization. (b) The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in
Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.
(c) The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services' Division of Alcoholism and Substance Abuse. (d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 101-81, eff. 7-12-19; 102-207, eff. 7-30-21.) |
(305 ILCS 5/5-5.26) Sec. 5-5.26. Multiple sclerosis; home services; waiver. The Department of Healthcare and Family Services shall apply for a waiver of federal law and regulations to the extent necessary to claim federal financial participation for medical assistance for services provided under the Department of Human Services' Home Services Program for persons with multiple sclerosis who are (i) over 60 years of age, and (ii) have assets not exceeding $17,500. In determining whether a person's assets meet this requirement, the Department must disregard retirement assets up to a total of $500,000 and disregard all life insurance assets.
(Source: P.A. 95-744, eff. 7-18-08.) |
(305 ILCS 5/5-5.27) Sec. 5-5.27. Coverage for clinical trials. (a) The medical assistance program shall provide coverage for routine care costs that are incurred in the course of an approved clinical trial if the medical assistance program would provide coverage for the same routine care costs not incurred in a clinical trial. "Routine care cost" shall be defined by the Department by rule. (b) The coverage that must be provided under this Section is subject to the terms, conditions, restrictions, exclusions, and limitations that apply generally under the medical assistance program, including terms, conditions, restrictions, exclusions, or limitations that apply to health care services rendered by participating providers and nonparticipating providers. (c) Implementation of this Section shall be contingent upon federal approval. Upon receipt of federal approval, if required, the Department shall adopt any rules necessary to implement this Section. (d) As used in this Section: "Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the prevention, detection, or treatment of cancer or any other life-threatening disease or condition if one or more of the following conditions apply: (1) the Department makes a determination that the | ||
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(2) the study or investigation is conducted under an | ||
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(3) the study or investigation is a drug trial that | ||
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(4) the study or investigation is approved or funded | ||
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(A) the National Institutes of Health; (B) the Centers for Disease Control and | ||
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(C) the Agency for Healthcare Research and | ||
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(D) the Patient-Centered Outcomes Research | ||
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(E) the federal Centers for Medicare and Medicaid | ||
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(F) a cooperative group or center of any of the | ||
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(G) a qualified non-governmental research entity | ||
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(H) the United States Department of Veterans | ||
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"Care method" means the use of a particular drug or device in a particular manner. "Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(Source: P.A. 101-649, eff. 7-7-20.) |
(305 ILCS 5/5-5a) (from Ch. 23, par. 5-5a)
Sec. 5-5a. Waiver for home and community-based services. The Department
shall apply for a waiver from the United States Health Care Financing
Administration to allow payment for home and community-based services under
this Article.
The Department, in cooperation with the Department on Aging, the Department
of Human Services and any other relevant State, local or
federal
government agency, may establish a nursing home pre-screening program to
determine whether the applicant, eligible for medical assistance under this
Article, may use home and community-based services as a reasonable,
lower-cost alternative form of care. For the purpose of this Section,
"home and community-based services" may include, but are not limited to,
those services provided under subsection (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and Section 4 of the Illinois Act on the Aging.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5-5a.1) Sec. 5-5a.1. Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. For dates of service on and after January 1, 2025, the Department shall pay negotiated, agreed upon administrative fees associated with implementing telehealth services for persons with intellectual and developmental disabilities who are receiving Community Integrated Living Arrangement residential services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities. The implementation of telehealth services shall not impede the choice of any individual receiving waiver-funded services through the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to receive in-person health care services at any time. The Department shall ensure individuals enrolled in the waiver, or their guardians, request to opt-in to these services. For individuals who opt in, this service shall be included in the individual's person-centered plan. The use of telehealth services shall not be used for the convenience of staff at any time nor shall it replace primary care physician services.(Source: P.A. 103-102, eff. 7-1-23; 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-5b) (from Ch. 23, par. 5-5b)
Sec. 5-5b.
Payment Reductions.
(a) Notwithstanding any other Section in this Code establishing a
methodology for determining payment rates or dispensing fees for
non-institutional services provided under this Code, the Illinois
Department is authorized to reduce those payment rates or dispensing fees
with due regard for and subject to budgetary limitations to the extent
permitted by federal law.
(b) The Illinois Department may implement this Section as added by
this amendatory Act of 1991 through the use of emergency rules in
accordance with the provisions of Section 5.02 of the Illinois
Administrative Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement this Section as added by
this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
(Source: P.A. 87-14.)
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(305 ILCS 5/5-5b.1) Sec. 5-5b.1. Reimbursement rates; Fiscal Year 2015 reductions. (a) Except as provided in subsection (b), notwithstanding any other provision of this Code to the contrary, and subject to rescission if not federally approved, providers of the following services shall have their reimbursement rates or dispensing fees reduced for the remainder of State fiscal year 2015 by an amount equivalent to a 2.25% reduction in appropriations from the General Revenue Fund for the medical assistance program for the full fiscal year: (1) Nursing facility services delivered by a nursing | ||
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(2) Home health services. (3) Services delivered by a facility designated as a | ||
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(4) Services delivered by a supportive living | ||
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(5) Services delivered by a specialized mental health | ||
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(6) Ambulance services. (7) Pharmacy services. (8) Services delivered by a federally qualified | ||
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(9) Services delivered by a Managed Care Entity, with | ||
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(10) Services for the treatment of hemophilia. (11) Primary care physician services. (12) Dental services. (13) Optometric services. (14) Podiatry services. (15) Hospice care, including routine home care, | ||
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(16) Laboratory services or services provided by | ||
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(17) Durable medical equipment and supplies. (18) Renal dialysis services. (19) Birth Center Services. (20) Emergency services other than those offered by | ||
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(b) No provider shall be exempt from the rate reductions authorized under this Section, except that, rates or payments, or the portion thereof, paid to a provider that is operated by a unit of local government that provides the non-federal share of such services shall not be reduced as provided in this Section. (c) To the extent practical and subject to rescission if not federally approved, the reductions required under this Section must be applied uniformly among and within each group, class, subgroup, or category of providers listed in this Section. (d) In order to provide for the expeditious and timely implementation of the provisions of this Section, emergency rules to implement any provision of this Section may be adopted by the Department in accordance with subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act.
(Source: P.A. 99-2, eff. 3-26-15.) |
(305 ILCS 5/5-5c)
Sec. 5-5c.
Waiver for home and community-based services for traumatic
brain injury (TBI) patients. The Department shall apply for a waiver from the
United States Health Care Financing Administration to allow payment for home
and community-based services under this Article for traumatic brain injury
patients.
The Department shall submit a Home and Community-Based
Services TBI
Waiver request to the United States Health Care Financing
Administration by January 1, 1998. The waiver shall be requested pursuant to
Section
1915(c) of the Social Security Act. The Department shall request a waiver of
Section 1902(a)(10)(B) of the Social Security Act in order to target home and
community-based services to individuals with a traumatic brain injury meeting
the Medicaid eligibility criteria set forth in appendices to the Prototype
Waiver request.
Under the waiver, the Department, in cooperation with the
Department of Human Services and any other relevant State, local, or federal
government agency, may establish a nursing facility pre-screening program to
determine whether an applicant who is eligible for medical assistance under
this Article and has a traumatic brain injury may use home and community-based
services as a reasonable, lower-cost alternative form of care. If a waiver
request has not been submitted by
January 1,
1998 the Department shall submit the TBI Prototype Waiver request to the
United States Health Care Financing Administration.
(Source: P.A. 90-335, eff. 8-8-97.)
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(305 ILCS 5/5-5d)
Sec. 5-5d. Enhanced transition and follow-up services. The Department of Healthcare and Family Services shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate the transition from one residential setting to another and follow-up services. Nothing in this Section shall be construed as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 95-331, eff. 8-21-07.) |
(305 ILCS 5/5-5e) Sec. 5-5e. Adjusted rates of reimbursement. (a) Rates or payments for services in effect on June 30, 2012 shall be adjusted and
services shall be affected as required by any other provision of Public Act 97-689. In addition, the Department shall do the following: (1) Delink the per diem rate paid for supportive | ||
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(2) Cease payment for bed reserves in nursing | ||
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(2.5) Cease payment for bed reserves for purposes of | ||
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(3) Cease payment of the $10 per day add-on payment | ||
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(b) After the application of subsection (a), notwithstanding any other provision of this
Code to the contrary and to the extent permitted by federal law, on and after July 1,
2012, the rates of reimbursement for services and other payments provided under this
Code shall further be reduced as follows: (1) Rates or payments for physician services, dental | ||
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(2) Rates or payments, or the portion thereof, paid | ||
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(3) Rates or payments for hospital services delivered | ||
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(4) Rates or payments for hospital services delivered | ||
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(5) Rates or payments for Nursing Facility Services | ||
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(6) Rates or payments for services delivered by long | ||
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(7) Rates or payments for services provided under | ||
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(8) For hospitals not previously described in this | ||
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(9) For all other rates or payments for services | ||
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(c) Any assessment imposed by this Code shall continue and nothing in this Section shall be construed to cause it to cease.
(d) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for services provided for the purpose of transitioning children from a hospital to home placement or other appropriate setting by a children's community-based health care center authorized under the Alternative Health Care Delivery Act shall be $683 per day. (e) (Blank). (f) (Blank). (Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-16, eff. 6-17-21; 102-687, eff. 12-17-21.) |
(305 ILCS 5/5-5e.1) Sec. 5-5e.1. Safety-Net Hospitals. (a) A Safety-Net Hospital is an Illinois hospital that: (1) is licensed by the Department of Public Health as | ||
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(2) is a disproportionate share hospital, as | ||
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(3) meets one of the following: (A) has a MIUR of at least 40% and a charity | ||
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(B) has a MIUR of at least 50%. (b) Definitions. As used in this Section: (1) "Charity percent" means the ratio of (i) the | ||
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(2) "MIUR" means Medicaid Inpatient Utilization Rate | ||
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(3) "OBRA form" means form HFS-3834, OBRA '93 data | ||
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(4) "Rate year" means the 12-month period beginning | ||
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(c) Beginning July 1, 2012 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2011 or October 1, 2012 shall be a Safety-Net Hospital. (c-5) Beginning July 1, 2020 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2020 and was designated a federal rural referral center under 42 CFR 412.96 as of October 1, 2020 shall be a Safety-Net Hospital. (d) No later than August 15 preceding the rate year, each hospital shall submit the OBRA form to the Department. Prior to October 1, the Department shall notify each hospital whether it has qualified as a Safety-Net Hospital. (e) The Department may promulgate rules in order to implement this Section.
(f) Nothing in this Section shall be construed as limiting the ability of the Department to include the Safety-Net Hospitals in the hospital rate reform mandated by Section 14-11 of this Code and implemented under Section 14-12 of this Code and by administrative rulemaking. (Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21; 102-886, eff. 5-17-22.) |
(305 ILCS 5/5-5e.2) Sec. 5-5e.2. Academic medical centers and major teaching hospital status. (a) Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria: (1) Tier I. A private academic medical center must: (A) be a hospital located in Illinois which is | ||
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(i) under common ownership with the college | ||
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(ii) a freestanding hospital in which the | ||
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(iii) a children's hospital which is | ||
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(B) serve as the training site for at least 30 | ||
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(C) facilitate the training on its campus or on | ||
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(D) perform, either itself or through its | ||
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(E) expend directly or indirectly through an | ||
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(2) Tier II. A public academic medical center must: (A) be a hospital located in Illinois which is a | ||
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(i) University of Illinois School of Medicine | ||
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(ii) University of Illinois School of | ||
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(iii) University of Illinois School of | ||
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(iv) University of Illinois School of | ||
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(v) Southern Illinois University School of | ||
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(B) contribute no less than $2,500,000 toward | ||
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(3) Tier III. A major teaching hospital must: (A) be an Illinois hospital with 100 or more | ||
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(B) support at least one graduate medical | ||
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(b) All hospitals seeking to qualify for Tier I, Tier II, or Tier III recognition must annually submit a report to the Department with supporting documentation and attesting to meeting the requirements in this Section. Such reporting must also describe each hospital's education and research activities for the preceding year.
(Source: P.A. 98-104, eff. 7-22-13.) |
(305 ILCS 5/5-5f)
Sec. 5-5f. Elimination and limitations of medical assistance services. Notwithstanding any other provision of this Code to the contrary, on and after July 1, 2012: (a) The following service shall no longer be a | ||
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(b) The Department shall place the following | ||
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(c) The Department shall require prior approval of | ||
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(d) The Department shall establish benchmarks for | ||
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(e) The Department shall establish utilization | ||
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(f) For home health services, the Department shall | ||
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(g) For the Home Services Program operated by the | ||
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(h) Effective with inpatient hospital admissions on | ||
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As used in this subsection (h): "Provider-preventable condition" means a health care | ||
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"Other provider-preventable condition" means a wrong | ||
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(i) The Department shall implement cost savings | ||
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(j) The Department shall ensure that beneficiaries | ||
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(Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section 5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21; 102-813, eff. 5-13-22.) |
(305 ILCS 5/5-5g) Sec. 5-5g. Long-term care patient; resident status. Long-term care providers shall submit all changes in resident status, including, but not limited to, death, discharge, changes in patient credit, third party liability, and Medicare coverage, to the Department through the Medical Electronic Data Interchange System, the Recipient Eligibility Verification System, or the Electronic Data Interchange System established under 89 Ill. Adm. Code 140.55(b) in compliance with the schedule below: (1) 15 calendar days after a resident's death; (2) 15 calendar days after a resident's discharge; (3) 45 calendar days after being informed of a change | ||
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(4) 45 calendar days after being informed of a change | ||
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(5) 45 calendar days after a resident's move to | ||
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(6) 45 calendar days after a resident's need for | ||
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(Source: P.A. 100-665, eff. 8-2-18.) |
(305 ILCS 5/5-5h) Sec. 5-5h. Long-term acute care hospital base rates. (a) The base per diem rate paid to long-term acute care hospitals for Medicaid services on and after January 1, 2020 must be $60 more than the base rate in effect on June 30, 2019. (b) Nothing in this Section shall change the rates authorized under Section 5A-12.6 or the Long-Term Acute Care Hospital Quality Improvement Transfer Program Act.
(Source: P.A. 101-10, eff. 6-5-19.) |
(305 ILCS 5/5-5i) Sec. 5-5i. Rate increase for speech, physical, and occupational therapy services. Subject to federal approval, beginning January 1, 2024, the Department shall increase reimbursement rates for speech therapy services, physical therapy services, and occupational therapy services provided by licensed speech-language pathologists and speech-language pathology assistants, physical therapists and physical therapy assistants, and occupational therapists and certified occupational therapy assistants, including those in their clinical fellowship, by 14.2%.(Source: P.A. 103-102, eff. 1-1-24.) |
(305 ILCS 5/5-6) (from Ch. 23, par. 5-6)
Sec. 5-6. Obligations incurred prior to death of a recipient. Obligations incurred but not paid for at the time of a recipient's death
for services authorized under Section 5-5, including medical and other
care in facilities as defined in the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act, or in like facilities
not required to be licensed under that Act, may be paid, subject to the
rules and regulations of the Illinois Department, after the death of the recipient.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
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(305 ILCS 5/5-7) (from Ch. 23, par. 5-7)
Sec. 5-7.
(Repealed).
(Source: P.A. 81-487. Repealed by P.A. 93-20, eff. 6-20-03.)
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(305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
Sec. 5-8. Practitioners. In supplying medical assistance, the Illinois
Department may provide for the legally authorized services of (i) persons
licensed under the Medical Practice Act of 1987, as amended, except as
hereafter in this Section stated, whether under a
general or limited license, (ii) persons licensed under the Nurse Practice Act as advanced practice registered nurses, regardless of whether or not the persons have written collaborative agreements, (iii) persons licensed or registered
under
other laws of this State to provide dental, medical, pharmaceutical,
optometric, podiatric, or nursing services, or other remedial care
recognized under State law, (iv) persons licensed under other laws of
this State as a clinical social worker, and (v) persons licensed under other laws of this State as physician assistants. The Department shall adopt rules, no later than 90 days after January 1, 2017 (the effective date of Public Act 99-621), for the legally authorized services of persons licensed under other laws of this State as a clinical social worker.
The Department shall provide for the legally authorized services of persons licensed under the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act as clinical professional counselors and for the legally
authorized services of persons licensed under the Marriage and
Family Therapy Licensing Act as marriage and family
therapists. The
utilization of the services of persons engaged in the treatment or care of
the sick, which persons are not required to be licensed or registered under
the laws of this State, is not prohibited by this Section.
(Source: P.A. 102-43, eff. 7-6-21.)
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(305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
Sec. 5-9. Choice of medical dispensers. Applicants and recipients shall
be entitled to free choice of those qualified practitioners, hospitals,
nursing homes, and other dispensers of medical services meeting the
requirements and complying with the rules and regulations of the Illinois
Department. However, the Director of Healthcare and Family Services may, after providing
reasonable notice and opportunity for hearing, deny, suspend or terminate
any otherwise qualified person, firm, corporation, association, agency,
institution, or other legal entity, from participation as a vendor of goods
or services under the medical assistance program authorized by this Article
if the Director finds such vendor of medical services in violation of this
Act or the policy or rules and regulations issued pursuant to this Act.
(Source: P.A. 100-538, eff. 1-1-18.)
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(305 ILCS 5/5-10) (from Ch. 23, par. 5-10)
Sec. 5-10.
Entitlement to Social Services.
Persons receiving medical
assistance shall be entitled to receive, under Article IX and the Illinois
Act on the Aging, such
rehabilitative, training or other social services as are appropriate to their
condition.
(Source: P.A. 92-651, eff. 7-11-02.)
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(305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
Sec. 5-11. Co-operative arrangements; contracts with other State
agencies, health care and rehabilitation organizations, and fiscal
intermediaries.
(a) The Illinois Department may enter into co-operative arrangements
with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
the end that there may be maximum utilization of such services in the
provision of medical assistance.
The Illinois Department shall, not later than June 30, 1993, enter into
one or more co-operative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with developmental disabilities, including but not
limited to intermediate care facilities, that are supported by State funds or
by funding under Title XIX of the federal Social Security Act. The
responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with such State health and
rehabilitation agencies and other public or private health care and
rehabilitation organizations to act for it in supplying designated medical
services to persons eligible therefor under this Article. Any contracts
with health services or health maintenance organizations shall be
restricted to organizations which have been certified as being in
compliance with standards promulgated pursuant to the laws of this State
governing the establishment and operation of health services or health
maintenance organizations. The Department shall renegotiate the contracts with health maintenance organizations and managed care community
networks that took effect August 1, 2003, so as to produce $70,000,000 savings to the Department net of resulting increases to the fee-for-service program for State fiscal year 2006. The Department may also contract with insurance
companies or other corporate entities serving as fiscal intermediaries in
this State for the Federal Government in respect to Medicare payments under
Title XVIII of the Federal Social Security Act to act for the Department in
paying medical care suppliers. The provisions of Section 9 of "An Act in
relation to State finance", approved June 10, 1919, as amended,
notwithstanding, such contracts with State agencies, other health care and
rehabilitation organizations, or fiscal intermediaries may provide for
advance payments.
(b) For purposes of this subsection (b), "managed care community
network" means an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care services within
this State and that provides or arranges primary, secondary, and tertiary
managed health care services under contract with the Illinois Department
exclusively to persons participating in programs administered by the Illinois
Department.
The Illinois Department may certify managed care community
networks, including managed care community networks owned, operated, managed,
or
governed by State-funded medical schools, as risk-bearing entities eligible to
contract with the Illinois Department as Medicaid managed care
organizations. The Illinois Department may contract with those managed
care community networks to furnish health care services to or arrange those
services for individuals participating in programs administered by the Illinois
Department. The rates for those provider-sponsored organizations may be
determined on a prepaid, capitated basis. A managed care community
network may choose to contract with the Illinois Department to provide only
pediatric
health care services.
The
Illinois Department shall by rule adopt the criteria, standards, and procedures
by
which a managed care community network may be permitted to contract with
the Illinois Department and shall consult with the Department of Insurance in
adopting these rules.
A county provider as defined in Section 15-1 of this Code may
contract with the Illinois Department to provide primary, secondary, or
tertiary managed health care services as a managed care
community network without the need to establish a separate entity and shall
be deemed a managed care community network for purposes of this Code
only to the extent it provides services to participating individuals. A county
provider is entitled to contract with the Illinois Department with respect to
any contracting region located in whole or in part within the county. A
county provider is not required to accept enrollees who do not reside within
the county.
In order
to (i) accelerate and facilitate the development of integrated health care in
contracting areas outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and sustain the high
quality of education and residency programs coordinated and associated with
local area hospitals, the Illinois Department may develop and implement a
demonstration program from managed care community networks owned, operated,
managed, or
governed by State-funded medical schools. The Illinois Department shall
prescribe by rule the criteria, standards, and procedures for effecting this
demonstration program.
A managed care community network that
contracts with the Illinois Department to furnish health care services to or
arrange those services for enrollees participating in programs administered by
the Illinois Department shall do all of the following:
(1) Provide that any provider affiliated with the | ||
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(2) Provide client education services as determined | ||
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(3) Provide that enrollees within the system may | ||
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(4) Not discriminate in enrollment or disenrollment | ||
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(5) Provide a quality assurance and utilization | ||
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(6) Issue a managed care community network | ||
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(A) The enrollee's health plan.
(B) The name and telephone number of the | ||
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(C) A telephone number to be used to confirm | ||
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(7) Ensure that every primary care physician and | ||
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(8) Provide a procedure for handling complaints that | ||
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(9) Maintain, retain, and make available to the | ||
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(10) (Blank).
The Illinois Department shall contract with an entity or entities to provide
external peer-based quality assurance review for the managed health care
programs administered by the Illinois Department. The entity shall meet all federal requirements for an external quality review organization.
Each managed care community network must demonstrate its ability to
bear the financial risk of serving individuals under this program.
The Illinois Department shall by rule adopt standards for assessing the
solvency and financial soundness of each managed care community network.
Any solvency and financial standards adopted for managed care community
networks
shall be no more restrictive than the solvency and financial standards adopted
under
Section 1856(a) of the Social Security Act for provider-sponsored
organizations under Part C of Title XVIII of the Social Security Act.
The Illinois
Department may implement the amendatory changes to this
Code made by this amendatory Act of 1998 through the use of emergency
rules in accordance with Section 5-45 of the Illinois Administrative Procedure
Act. For purposes of that Act, the adoption of rules to implement these
changes is deemed an emergency and necessary for the public interest,
safety, and welfare.
(c) Not later than June 30, 1996, the Illinois Department shall
enter into one or more cooperative arrangements with the Department of Public
Health for the purpose of developing a single survey for
nursing facilities, including but not limited to facilities funded under Title
XVIII or Title XIX of the federal Social Security Act or both, which shall be
administered and conducted solely by the Department of Public Health.
The Departments shall test the single survey process on a pilot basis, with
both the Departments of Public Aid and Public Health represented on the
consolidated survey team. The pilot will sunset June 30, 1997. After June 30,
1997, unless otherwise determined by the Governor, a single survey shall be
implemented by the Department of Public Health which would not preclude staff
from the Department of Healthcare and Family Services (formerly Department of Public Aid) from going on-site to nursing facilities to
perform necessary audits and reviews which shall not replicate the single State
agency survey required by this Act. This Section shall not apply to community
or intermediate care facilities for persons with developmental disabilities.
(d) Nothing in this Code in any way limits or otherwise impairs the
authority or power of the Illinois Department to enter into a negotiated
contract pursuant to this Section with a managed care community network or
a health maintenance organization, as defined in the Health Maintenance
Organization Act, that provides for
termination or nonrenewal of the contract without cause, upon notice as
provided in the contract, and without a hearing.
(Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)
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(305 ILCS 5/5-11.1)
Sec. 5-11.1. Cooperative arrangements; contracts. The Illinois Department
may enter into cooperative
arrangements with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
maximize utilization of these services in the provision of medical assistance.
The Illinois Department shall, not later than June 30, 1994, enter into
one or more cooperative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with mental illness, including but not limited to
intermediate care facilities, that are supported by State funds or by funding
under Title XIX of the federal Social Security Act.
The responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with State health and rehabilitation
agencies and other public or private health care and rehabilitation
organizations to act for it in supplying designated medical services to persons
eligible under this Section. Any contracts with health services or health
maintenance organizations shall be restricted to organizations which have been
certified as being in compliance with standards promulgated under the laws of
this State governing the establishment and operation of health services or
health maintenance organizations. The Department may also contract with
insurance companies or other corporate entities serving as fiscal
intermediaries in this State for the federal government in respect to Medicare
payments under Title XVIII of the federal Social Security Act to act for the
Department in paying medical care suppliers. Nothing in this Section shall be
construed to abrogate any existing doctor/patient relationships with
Department of Healthcare and Family Services recipients or the free choice of clients or their
guardians to select a physician to provide medical care. The provisions of
Section 9 of the State Finance Act notwithstanding, such contracts with State
agencies, other health care and rehabilitation organizations, or fiscal
intermediaries may provide for advance payments.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/5-11a) Sec. 5-11a. Health Benefit Information Systems. (a) It is the intent of the General Assembly to support unified electronic systems initiatives that will improve management of information related to medical assistance programs. This will include improved management capabilities and new systems for Eligibility, Verification, and Enrollment (EVE) that will simplify and increase efficiencies in and access to the medical assistance programs and ensure program integrity. The Department of Healthcare and Family Services, in coordination with the Department of Human Services and other appropriate state agencies, shall develop a plan by July 1, 2011, that will: (1) Subject to federal and State privacy and | ||
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(2) Receive and update data electronically from the | ||
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(3) Meet federal requirements for timely installation | ||
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(4) Meet federal requirements for compliance with | ||
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(5) Include plans to ensure coordination with the | ||
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(b) The Department of Healthcare and Family Services shall continue to plan for and implement a new Medicaid Management Information System (MMIS) and upgrade the capabilities of the MMIS data warehouse. Upgrades shall include, among other things, enhanced capabilities in data analysis including the ability to identify risk factors that could impact the treatment and resulting quality of care, and tools that perform predictive analytics on data applying to newborns, women with high risk pregnancies, and other populations served by the Department. (c) The Department of Healthcare and Family Services shall report in its annual Medical Assistance program report each April through April, 2015 on the progress and implementation of this plan.
(Source: P.A. 96-1501, eff. 1-25-11.) |
(305 ILCS 5/5-12) (from Ch. 23, par. 5-12)
Sec. 5-12.
Funeral and burial.
Upon the death of a recipient who
qualified under class 2, 3 or 4 of Section 5-2, if his estate is
insufficient to pay his funeral and burial expenses and if no other
resources, including assistance from legally responsible relatives, are
available for such purposes, there shall be paid, in accordance with the
standards, rules and regulations of the Illinois Department of Human
Services, such reasonable amounts as may be necessary to meet the costs of
the funeral, burial space, and cemetery charges, or to reimburse any person not
financially responsible for the deceased who has voluntarily made
expenditures for such costs.
(Source: P.A. 92-651, eff. 7-11-02.)
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(305 ILCS 5/5-13) (from Ch. 23, par. 5-13)
Sec. 5-13. Claim against estate of recipients. To the extent permitted under
the federal Social Security Act, the amount expended under this Article (1) for
a person of any age who is an inpatient in a nursing facility, an intermediate
care facility for persons with intellectual disabilities, or other medical institution, or (2)
for a person aged 55 or more, shall be a claim against the person's
estate or a claim against the estate of the person's spouse,
regardless of the order of death, but no recovery may
be had thereon until after the death of the surviving spouse, if any, and then
only at such time when there is no surviving child who is under age 21, or
blind, or is a child with a permanent total disability. This Section, however, shall not
bar recovery at the death of the person of amounts of medical assistance paid
to or in his behalf to which he was not entitled; provided that such
recovery shall not be enforced against any real estate while it is occupied
as a homestead by the surviving spouse or other dependent, if no claims by
other creditors have been filed against the estate, or if such claims have
been filed, they remain dormant for failure of prosecution or failure of
the claimant to compel administration of the estate for the purpose of
payment. The term "estate", as used in this Section, with respect to a
deceased person, means all real and personal property and other assets included
within the person's estate, as that term is used in the Probate Act of 1975;
however, in the case of a deceased person who has received (or is entitled to
receive) benefits under a long-term care insurance policy in connection with
which assets or resources are disregarded to the extent that payments are made
or because the deceased person received (or was entitled to receive) benefits
under a long-term care insurance policy, "estate" also includes any
other real and personal property and other assets in which the deceased person
had any legal title or interest at the time of his or her death (to the extent
of that interest), including assets conveyed to a survivor, heir, or assignee
of the deceased person through joint tenancy, tenancy in common, survivorship,
life estate, living trust, or other arrangement. The term "homestead", as used
in this Section, means the dwelling house and contiguous real estate occupied
by a surviving spouse or relative, as defined by the rules and regulations of
the Illinois Department, regardless of the value of the property.
A claim arising under this Section against assets conveyed to a survivor,
heir, or assignee of the deceased person through joint tenancy, tenancy in
common, survivorship, life estate, living trust, or other arrangement is not
effective until the claim is recorded or filed in the manner provided for a
notice of lien in Section 3-10.2. The claim is subject to the same
requirements and conditions to which liens on real property interests are
subject under Sections 3-10.1 through 3-10.10. A claim arising under this
Section attaches to interests owned or subsequently acquired by the estate of a
recipient or the estate of a recipient's surviving spouse.
The transfer or conveyance of any real or personal property of the estate
as
defined in this Section shall be subject to the fraudulent transfer conditions
that apply to real property in Section 3-11 of this Code.
The provisions of this Section shall not affect the validity of claims
against estates for medical assistance provided prior to January 1, 1966 to
aged or blind persons or persons with disabilities receiving aid under Articles V, VII and
VII-A of the 1949 Code.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5-13.1) Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers, and making information about waivers more accessible. (a) It is the intent of the General Assembly to ease the burden of liens and estate recovery for correctly paid benefits for participants, applicants, and their families and heirs, and to make information about waivers more widely available. (b) The Department shall waive estate recovery under Sections 3-9 and 5-13 where recovery would not be cost-effective, would work an undue hardship, or for any other just reason, and shall make information about waivers and estate recovery easily accessible. (1) Cost-effectiveness waiver. Subject to federal | ||
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(2) Undue hardship waiver. The Department may develop | ||
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(3) Accessible information. The Department shall make | ||
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(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-13.2)
Sec. 5-13.2.
Notice of claim for payment or against estate.
If the Illinois Department determines, more than 120 days after a person
becomes an institutionalized person, that (i) the institutionalized person, the
institutionalized person's spouse, or any other person is required under this
Code to reimburse the Illinois Department for any part of the amount of medical
assistance provided under this Article to or on behalf of the institutionalized
person or (ii) the institutionalized person's estate is liable for any amount
of medical assistance provided to or on behalf of the institutionalized person,
the Illinois Department shall not make any claim for payment of that amount on
demand, but rather shall establish, in cooperation with the institutionalized
person (and that person's spouse or primary caretaker, if applicable), a
schedule for payment of the amount owed to the Illinois Department.
(Source: P.A. 88-162; 88-670, eff. 12-2-94.)
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(305 ILCS 5/5-13.5)
Sec. 5-13.5. (Repealed).
(Source: P.A. 88-670, eff. 12-2-94. Repealed by P.A. 102-1037, eff. 6-2-22.)
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(305 ILCS 5/5-14) (from Ch. 23, par. 5-14)
Sec. 5-14.
Exemption for Townships.
Nothing in this Article shall be
construed as requiring townships to provide, in whole or in part, medical
assistance to persons who are not residents of the State of Illinois.
In all instances under this Article where medical aid or assistance to
a person who is not a resident of this State would otherwise be in whole
or in part, the responsibility of a township, the Illinois Department shall
be responsible for such aid or assistance.
The Illinois Department shall, by rule or regulation, insure that provision
of such aid or assistance to a non-resident is identical to the uniform
standard of eligibility established by the Illinois Department.
(Source: P.A. 81-519.)
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(305 ILCS 5/5-15) (from Ch. 23, par. 5-15)
Sec. 5-15. (a) The Illinois Department is authorized to contract
with community based organizations serving low income communities for a
three year period to demonstrate how and the extent to which preventive
health programs can decrease utilization of medical care services and/or
improve health status.
(b) As used in this Section (1) a community based organization is an
organization established as a not-for-profit corporation under laws of the
State of Illinois which serves a defined geographic community and is
governed by members of that community; and (2) a preventive health program
is any program, service or intervention the purpose of which is to
identify, resolve, or ameliorate problems which contribute to the
utilization of medical services.
(c) The Illinois Department is authorized, for evaluation purposes, to
release names of recipients and other pertinent identification and medical
utilization information to the community organizations under contract.
(d) Contractors shall maintain strict confidentiality of information
released by the Illinois Department by following guidelines established by
the Illinois Department, which shall require that recipients sign a release
for any further use or disclosure of such information.
(Source: P.A. 93-632, eff. 2-1-04.)
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(305 ILCS 5/5-15.5)
Sec. 5-15.5.
Preventive physical examinations; demonstration program.
(a) The Illinois Department may establish and implement a demonstration
program of preventive physical examinations over a 3-year period commencing on
January 1, 1994, for persons receiving assistance under Article IV of this
Code and persons eligible for assistance under this Article who are otherwise
eligible for assistance under Article IV but who fail to qualify for cash
assistance under Article IV on the basis of need. Notwithstanding any other
provision of this Section, however, persons who are pregnant or who are less
than 21 years of age shall not be eligible to participate in the demonstration
program. The demonstration program may be implemented for recipients in at
least 2 counties, one with a population of not more than 650,000 as determined
by the 1990 federal census, and one with a population of not more than 100,000
as determined by the 1990 federal census. The Illinois Department may
establish by rule the nature and scope of the preventive physical examinations
required under this Section, except that the services may include, as
appropriate, blood pressure reading, complete blood test appropriate to the
population and risk factors, family planning, nutrition counselling, smoking
evaluation, temperature, urinalysis, chest x-ray, tuberculosis screening, and
appropriate referrals.
(b) Participation in the demonstration program shall be voluntary, and
eligible recipients shall not be subject to sanctions for refusing or failing
to submit to a preventive physical examination or any portion of such an
examination. The Illinois Department may by rule limit each eligible recipient
to one examination during the demonstration period.
(c) For the purpose of carrying out its responsibilities under this Section,
the Illinois Department is authorized to enter into cooperative arrangements
with for-profit and non-profit medical clinics and hospitals, local health
departments, and other providers of medical services. The Illinois Department
of Public Health shall cooperate in the development and establishment of this
demonstration program. During the period of the demonstration program, the
Illinois Department of Public Aid shall study the cost benefit of providing
preventive physical examinations to the targeted group of recipients of public
aid.
(d) Implementation of the demonstration program shall be contingent on the
receipt of all necessary federal waivers.
(Source: P.A. 88-396.)
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(305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
Sec. 5-16.
Managed Care.
The Illinois Department may develop and implement
a Primary Care Sponsor System consistent with the provisions of this Section.
The purpose of this managed care delivery system shall be to contain the costs
of providing medical care to Medicaid recipients by having one provider
responsible for managing all aspects of a recipient's medical care. This
managed care system shall have the following characteristics:
(a) The Department, by rule, shall establish criteria | ||
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(b) Providers participating in the program may be | ||
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(c) Providers eligible to participate in the program | ||
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(d) Each recipient required to participate in the | ||
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(e) A recipient may change his designated primary | ||
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(1) when the designated source becomes | ||
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(2) when the designated primary care provider | ||
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(3) in other situations, as the Illinois | ||
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(f) The Illinois Department shall, by rule, establish | ||
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(g) Only medical care services authorized by a | ||
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The Illinois Department shall seek and obtain necessary authorization
provided under federal law to implement such a program including the waiver of
any federal regulations.
The Illinois Department may implement the amendatory changes to
this Section made by this amendatory Act of 1991 through the use of emergency
rules in accordance with the provisions of Section 5.02 of the Illinois
Administrative Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement the amendatory changes to
this Section made by this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
The Illinois Department may establish a managed care system demonstration
program, on a limited basis, as described in this Section. The demonstration
program shall terminate on June 30, 1997. Within 30 days after the end of each
year of the demonstration program's operation, the Illinois Department shall
report to the Governor and the General Assembly concerning the operation of the
demonstration program.
(Source: P.A. 87-14; 88-490.)
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(305 ILCS 5/5-16.1) (from Ch. 23, par. 5-16.1)
Sec. 5-16.1. Case Management Services. The Illinois Department may
develop, implement and evaluate a Case Management Services Program which
provides services consistent with the provisions of this Section, and the
Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the
Department of Public Health, for a targeted population on a less than
Statewide basis in the State of Illinois. The purpose of this Case
Management Services Program shall be to assist eligible participants in
gaining access to needed medical, social, educational and other services
thereby reducing the likelihood of long-term welfare dependency. The Case
Management Services Program shall have the following characteristics:
(a) It shall be conducted for a period of no less | ||
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(b) Providers participating in the program shall be | ||
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(c) Providers eligible to participate in the program | ||
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(d) Each eligible participant in an area where the | ||
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(e) A participant may change her designated case | ||
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(f) The Illinois Department shall, by rule, establish | ||
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(g) In accordance with rules adopted by the Illinois | ||
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The Illinois Department shall take any necessary steps to obtain
authorization or waiver under federal law to implement a Case Management
Services Program. Participation shall be voluntary for the provider and
the recipient.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/5-16.2)
Sec. 5-16.2.
Long range plan for case management.
The Illinois Department
shall develop a long range plan for the implementation of case management
services, as defined in Section 5-16.1 of this Act, throughout Illinois. The
long range plan shall include: (i) a geographic overview of the State and the
proportion, as determined by the Department of Public Aid and the Department of
Public Health records, of Medicaid eligible pregnant or parenting girls under
17 years of age at the time of the initial assessment; (ii) identification of
high proportion areas; (iii) goals for reducing the likelihood of long-term
welfare dependency; (iv) the time frames for accomplishing the identified
goals; and (v) specific recommendations for administrative or legislative
policies and programs necessary to complete the identified goals. The long
range plan shall take into consideration other resources currently serving the
identified population. The long range plan shall be completed no later than
July 1, 1994, and provided to the Governor and the General Assembly in the form
of a written report.
(Source: P.A. 88-70.)
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(305 ILCS 5/5-16.3)
Sec. 5-16.3.
(Repealed).
(Source: P.A. 90-742, eff. 8-13-98. Repealed by P.A. 92-370, eff. 8-15-01.)
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(305 ILCS 5/5-16.4)
Sec. 5-16.4. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 99-933, eff. 1-27-17.)
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(305 ILCS 5/5-16.5)
Sec. 5-16.5.
Expedited payments.
(a) (Blank).
(b) In a county with a population of 3,000,000 or more, a managed care
community network shall receive expedited payment of its capitated
reimbursement for each of its managed care enrollees if both of the following
criteria are met:
(1) At least 75% of its membership is composed of | ||
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(2) At least 75% of its managed care enrollees | ||
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(c) For counties whose population is less than 3,000,000, the Illinois
Department shall establish by rule the terms and conditions under which a
managed care community network shall receive expedited payment, including a
determination of the qualifying percentage criteria for
disproportionate share hospitals and managed care enrollees
within a network receiving services at disproportionate share hospitals or
their affiliated sites.
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95.)
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(305 ILCS 5/5-16.6)
Sec. 5-16.6.
Provider compliance with certain requirements.
The Illinois
Department shall inquire of appropriate State agencies concerning the status of
all providers' compliance with State income tax requirements, child support
payments in accordance with Article X of this Code, and educational loans
guaranteed by the Illinois State Scholarship Commission. The Illinois
Department may suspend from participation in the medical assistance program,
after reasonable notice and opportunity for a hearing in accordance with
Section
12-4.25 of this Code, those providers not in compliance with
these
requirements, unless payment arrangements acceptable to the appropriate State
agency are made.
(Source: P.A. 90-655, eff. 7-30-98.)
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(305 ILCS 5/5-16.7)
(Text of Section before amendment by P.A. 103-720)
Sec. 5-16.7. Post-parturition care. The medical assistance program shall
provide the post-parturition care benefits required to be covered by a policy
of accident and health insurance under Section 356s of the
Illinois Insurance Code.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)
(Text of Section after amendment by P.A. 103-720) Sec. 5-16.7. Post-parturition care. The medical assistance program shall provide the post-parturition care benefits required to be covered by a policy of accident and health insurance under Section 356s of the Illinois Insurance Code. (Source: P.A. 103-720, eff. 1-1-26.) |
(305 ILCS 5/5-16.7a)
Sec. 5-16.7a. Reimbursement for epidural anesthesia services.
In addition to other procedures authorized by the
Department under this Code, the
Department shall provide reimbursement to medical providers for epidural
anesthesia services when ordered by the attending practitioner at the time of
delivery.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.) |
(305 ILCS 5/5-16.8) (Text of Section from P.A. 103-605) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, 356z.61, 356z.64, and 356z.67 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act. The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate. (Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-605, eff. 7-1-24.) (Text of Section from P.A. 103-703) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.59, 356z.60, 356z.61, 356z.64, and 356z.67 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act. The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate. (Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-703, eff. 1-1-26.) (Text of Section from P.A. 103-758 and 103-1024) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, 356z.61, 356z.64, 356z.67, and 356z.71 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act. The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate. (Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25.) |
(305 ILCS 5/5-16.8a) Sec. 5-16.8a. Rules concerning continuous glucose monitor coverage. The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules shall, at a minimum, provide that: (1) the ordering provider must be a physician | ||
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(2) continuous glucose monitors are not required to | ||
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(3) the beneficiary is not required to need intensive | ||
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(4) the beneficiary is not required to have a recent | ||
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(5) if the beneficiary has gestational diabetes, the | ||
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(6) if a beneficiary has diabetes mellitus and the | ||
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(7) prior authorization is required for a | ||
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(Source: P.A. 103-639, eff. 7-1-24.) |
(305 ILCS 5/5-16.9) Sec. 5-16.9. Access to obstetrical and gynecological care. The medical assistance program is subject to the provisions of Section 356r of the Illinois Insurance Code. The Illinois Department shall adopt rules to implement the requirements of Section 356r of the Illinois Insurance Code in the medical assistance program including managed care components. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 103-718, eff. 7-19-24.) |
(305 ILCS 5/5-16.10)
Sec. 5-16.10.
Managed care entities; marketing.
A managed health care entity
providing services under this Article V
may not engage in door-to-door
marketing activities or marketing activities at an office of the Illinois
Department or a county department in order to enroll
recipients
in the entity's health
care
delivery system. The Department shall adopt rules defining "marketing
activities" prohibited by this Section.
Before a managed health care entity
providing services under this Article V
may market its health care delivery
system
to recipients,
the Illinois Department must approve a marketing plan submitted
by the entity to the Illinois Department. The Illinois Department shall adopt
guidelines for approving marketing plans submitted by managed health care
entities under this Section. Besides prohibiting door-to-door marketing
activities and marketing activities at public aid offices, the guidelines shall
include at least the following:
(1) A managed health care entity may not offer or | ||
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(2) All persons employed or otherwise engaged by a | ||
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The Inspector General appointed under Section 12-13.1 may conduct
investigations to determine whether the marketing practices of managed health
care entities
providing services under this Article V
comply with
the guidelines.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/5-16.11)
Sec. 5-16.11.
Uniform standards applied to managed care entities.
Any
managed care entity providing services under this Code shall use a pharmacy
formulary that is no more restrictive than the Illinois Department's
pharmaceutical program.
(Source: P.A. 92-370, eff. 8-15-01.)
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(305 ILCS 5/5-16.12)
(Text of Section before amendment by P.A. 103-650)
Sec. 5-16.12.
Managed Care Reform and Patient Rights Act.
The medical
assistance
program and other programs administered by the Department are subject to the
provisions of the Managed Care Reform and Patient Rights Act.
The
Department may adopt rules
to
implement those provisions. These rules shall require compliance with
that Act in
the medical assistance managed care programs and other programs administered by
the Department. The medical assistance
fee-for-service program is not subject to the provisions of the Managed Care
Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act shall be
construed to mean that the Department is a health care plan as defined in that
Act simply because the Department enters into contractual relationships with
health care plans.
(Source: P.A. 91-617, eff. 1-1-00.)
(Text of Section after amendment by P.A. 103-650) Sec. 5-16.12. Managed Care Reform and Patient Rights Act. The medical assistance program and other programs administered by the Department are subject to the provisions of the Managed Care Reform and Patient Rights Act. The Department may adopt rules to implement those provisions. These rules shall require compliance with that Act in the medical assistance managed care programs and other programs administered by the Department. The medical assistance fee-for-service program is not subject to the provisions of the Managed Care Reform and Patient Rights Act, except for Sections 85 and 87 of the Managed Care Reform and Patient Rights Act and for any definition in Section 10 of the Managed Care Reform and Patient Rights Act that applies to Sections 85 and 87 of the Managed Care Reform and Patient Rights Act. Nothing in the Managed Care Reform and Patient Rights Act shall be construed to mean that the Department is a health care plan as defined in that Act simply because the Department enters into contractual relationships with health care plans; provided that this clause shall not defeat the applicability of Sections 10, 85, and 87 of the Managed Care Reform and Patient Rights Act to the fee-for-service program.(Source: P.A. 103-650, eff. 1-1-25.)
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(305 ILCS 5/5-16.13) Sec. 5-16.13. (Repealed).(Source: P.A. 93-674, eff. 6-10-04. Repealed internally, eff. 12-31-04.) |
(305 ILCS 5/5-17) (from Ch. 23, par. 5-17)
Sec. 5-17. Programs to improve access to hospital care.
(a) (1) The General Assembly finds:
(A) That while hospitals have traditionally | ||
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(B) That access to hospital care in this State by | ||
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(2) To help expand the availability of hospital care | ||
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(3) The Illinois Department may develop and implement | ||
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(b) The Illinois Department shall require hospitals certified to
participate in the federal Medicaid program to:
(1) provide equal access to available services to | ||
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(2) provide data and reports on the provision of | ||
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(c) From the effective date of this amendatory Act of 1992 until July
1, 1992, nothing in this Section 5-17 shall be construed as creating a
private right of action on behalf of any individual.
(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/5-18) (from Ch. 23, par. 5-18)
Sec. 5-18.
(Repealed).
(Source: P.A. 87-895. Repealed by P.A. 92-275, eff. 8-7-01.)
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(305 ILCS 5/5-18.3) Sec. 5-18.3. Birth center; facility fee. (a) Reimbursement for services covered under this Article and provided at a birth center as defined in Section 5 of the Birth Center Licensing Act shall include: (1) Beginning January 1, 2025, subject to federal | ||
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(2) Beginning January 1, 2025, no less than 80% of | ||
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(b) The Department shall submit any necessary application to the federal Centers for Medicare and Medicaid Services for a waiver or State Plan amendment to implement the requirements of this Section.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-18.5) (Text of Section before amendment by P.A. 103-720) Sec. 5-18.5. Perinatal doula and evidence-based home visiting services. (a) As used in this Section: "Home visiting" means a voluntary, evidence-based strategy used to support pregnant people, infants, and young children and their caregivers to promote infant, child, and maternal health, to foster educational development and school readiness, and to help prevent child abuse and neglect. Home visitors are trained professionals whose visits and activities focus on promoting strong parent-child attachment to foster healthy child development. "Perinatal doula" means a trained provider who provides regular, voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period. "Perinatal doula training" means any doula training that focuses on providing support throughout the prenatal, labor and delivery, or postpartum period, and reflects the type of doula care that the doula seeks to provide. (b) Notwithstanding any other provision of this Article, perinatal doula services and evidence-based home visiting services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. Perinatal doula services include regular visits beginning in the prenatal period and continuing into the postnatal period, inclusive of continuous support during labor and delivery, that support healthy pregnancies and positive birth outcomes. Perinatal doula services may be embedded in an existing program, such as evidence-based home visiting. Perinatal doula services provided during the prenatal period may be provided weekly, services provided during the labor and delivery period may be provided for the entire duration of labor and the time immediately following birth, and services provided during the postpartum period may be provided up to 12 months postpartum. (b-5) Notwithstanding any other provision of this Article, beginning January 1, 2023, licensed certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. The Department shall consult with midwives on reimbursement rates for midwifery services. (c) The Department of Healthcare and Family Services shall adopt rules to administer this Section. In this rulemaking, the Department shall consider the expertise of and consult with doula program experts, doula training providers, practicing doulas, and home visiting experts, along with State agencies implementing perinatal doula services and relevant bodies under the Illinois Early Learning Council. This body of experts shall inform the Department on the credentials necessary for perinatal doula and home visiting services to be eligible for Medicaid reimbursement and the rate of reimbursement for home visiting and perinatal doula services in the prenatal, labor and delivery, and postpartum periods. Every 2 years, the Department shall assess the rates of reimbursement for perinatal doula and home visiting services and adjust rates accordingly. (d) The Department shall seek such State plan amendments or waivers as may be necessary to implement this Section and shall secure federal financial participation for expenditures made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.) (Text of Section after amendment by P.A. 103-720) Sec. 5-18.5. Perinatal doula and evidence-based home visiting services. (a) As used in this Section: "Home visiting" means a voluntary, evidence-based strategy used to support pregnant people, infants, and young children and their caregivers to promote infant, child, and maternal health, to foster educational development and school readiness, and to help prevent child abuse and neglect. Home visitors are trained professionals whose visits and activities focus on promoting strong parent-child attachment to foster healthy child development. "Perinatal doula" means a trained provider who provides regular, voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period. "Perinatal doula training" means any doula training that focuses on providing support throughout the prenatal, labor and delivery, or postpartum period, and reflects the type of doula care that the doula seeks to provide. (b) Notwithstanding any other provision of this Article, perinatal doula services and evidence-based home visiting services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. Perinatal doula services include regular visits beginning in the prenatal period and continuing into the postnatal period, inclusive of continuous support during labor and delivery, that support healthy pregnancies and positive birth outcomes. Perinatal doula services may be embedded in an existing program, such as evidence-based home visiting. Perinatal doula services provided during the prenatal period may be provided weekly, services provided during the labor and delivery period may be provided for the entire duration of labor and the time immediately following birth, and services provided during the postpartum period may be provided up to 12 months postpartum. (b-5) Notwithstanding any other provision of this Article, beginning January 1, 2023, licensed certified professional midwife services and, beginning January 1, 2025, certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. The Department shall consult with midwives on reimbursement rates for midwifery services. (c) The Department of Healthcare and Family Services shall adopt rules to administer this Section. In this rulemaking, the Department shall consider the expertise of and consult with doula program experts, doula training providers, practicing doulas, and home visiting experts, along with State agencies implementing perinatal doula services and relevant bodies under the Illinois Early Learning Council. This body of experts shall inform the Department on the credentials necessary for perinatal doula and home visiting services to be eligible for Medicaid reimbursement and the rate of reimbursement for home visiting and perinatal doula services in the prenatal, labor and delivery, and postpartum periods. Every 2 years, the Department shall assess the rates of reimbursement for perinatal doula and home visiting services and adjust rates accordingly. (d) The Department shall seek such State plan amendments or waivers as may be necessary to implement this Section and shall secure federal financial participation for expenditures made by the Department in accordance with this Section.(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22; 103-720, eff. 1-1-25.) |
(305 ILCS 5/5-18.10) Sec. 5-18.10. Reimbursement for postpartum visits. (a) In this Section: "Certified lactation counselor" means a health care professional in lactation counseling who has demonstrated the necessary skills, knowledge, and attitudes to provide clinical breastfeeding counseling and management support to families who are thinking about breastfeeding or who have questions or problems during the course of breastfeeding. "Certified nurse midwife" means a person who exceeds the competencies for a midwife contained in the Essential Competencies for Midwifery Practice, published by the International Confederation of Midwives, and who qualifies as an advanced practice registered nurse. "Community health worker" means a frontline public health worker who is a trusted member or has an unusually close understanding of the community served. This trusting relationship enables the community health worker to serve as a liaison, link, and intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. "International board-certified lactation consultant" means a health care professional who is certified by the International Board of Lactation Consultant Examiners and specializes in the clinical management of breastfeeding. "Medical caseworker" means a health care professional who assists in the planning, coordination, monitoring, and evaluation of medical services for a patient with emphasis on quality of care, continuity of services, and affordability. "Perinatal doula" means a trained provider of regular and voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period. "Public health nurse" means a registered nurse who promotes and protects the health of populations using knowledge from nursing, social, and public health sciences. (b) The Illinois Department shall establish a medical assistance program to cover a universal postpartum visit within the first 3 weeks after childbirth and a comprehensive visit within 4 to 12 weeks postpartum for persons who are otherwise eligible for medical assistance under this Article. In addition, postpartum care services rendered by perinatal doulas, certified lactation counselors, international board-certified lactation consultants, public health nurses, certified nurse midwives, community health workers, and medical caseworkers shall be covered under the medical assistance program.
(Source: P.A. 102-665, eff. 10-8-21.) |
(305 ILCS 5/5-19) (from Ch. 23, par. 5-19)
Sec. 5-19. Healthy Kids Program.
(a) Any child under the age of 21 eligible to receive Medical Assistance
from the Illinois Department under Article V of this Code shall be eligible
for Early and Periodic Screening, Diagnosis and Treatment services provided
by the Healthy Kids Program of the Illinois Department under the Social
Security Act, 42 U.S.C. 1396d(r).
(b) Enrollment of Children in Medicaid. The Illinois Department shall
provide for receipt and initial processing of applications for Medical
Assistance for all pregnant women and children under the age of 21 at
locations in addition to those used for processing applications for cash
assistance, including disproportionate share hospitals, federally qualified
health centers and other sites as selected by the Illinois Department.
(c) Healthy Kids Examinations. The Illinois Department shall consider
any examination of a child eligible for the Healthy Kids services provided
by a medical provider meeting the requirements and complying with the rules
and regulations of the Illinois Department to be reimbursed as a Healthy
Kids examination.
(d) Medical Screening Examinations.
(1) The Illinois Department shall insure Medicaid | ||
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(2) The Illinois Department shall pay for an | ||
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(A) requested by a child's parent, guardian, or | ||
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(B) necessary for enrollment in school; or
(C) necessary for enrollment in a licensed day | ||
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(D) necessary for placement in a licensed child | ||
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(E) necessary for attendance at a camping | ||
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(F) necessary for participation in an organized | ||
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(G) necessary for enrollment in an early | ||
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(H) necessary for participation in a Women, | ||
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(I) deemed appropriate by the Illinois Department.
(e) Minimum Screening Protocols For Periodic Health Screening
Examinations. Health Screening Examinations must include the following
services:
(1) Comprehensive Health and Development Assessment | ||
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(A) Development/Mental Health/Psychosocial | ||
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(B) Assessment of nutritional status including | ||
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(2) Comprehensive unclothed physical exam;
(3) Appropriate immunizations at a minimum, as | ||
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(4) Appropriate laboratory tests including blood lead | ||
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(A) Anemia test.
(B) Sickle cell test.
(C) Tuberculin test at 12 months of age and every | ||
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(D) Other -- The Illinois Department shall insure | ||
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(5) Health Education. The Illinois Department shall | ||
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(6) Vision Screening. The Illinois Department shall | ||
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(7) Hearing Screening. The Illinois Department shall | ||
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(8) Dental Screening. The Illinois Department shall | ||
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(f) Covered Medical Services. The Illinois Department shall provide
coverage for all necessary health care, diagnostic services, treatment and
other measures to correct or ameliorate defects, physical and mental
illnesses, and conditions whether discovered by the screening services or
not for all children eligible for Medical Assistance under Article V of
this Code.
(g) Notice of Healthy Kids Services.
(1) The Illinois Department shall inform any child | ||
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(2) The Illinois Department shall widely disseminate | ||
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(3) The Illinois Department shall utilize accepted | ||
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(4) The Illinois Department shall provide notice of | ||
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(A) orally by the intake worker and in writing at | ||
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(B) at the time the applicant is informed that he | ||
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(C) at least 20 days before the date of any | ||
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(h) Data Collection. The Illinois Department shall collect data in a
usable form to track utilization of Healthy Kids screening examinations by
children eligible for Healthy Kids services, including but not limited to
data showing screening examinations and immunizations received, a summary
of follow-up treatment received by children eligible for Healthy Kids
services and the number of children receiving dental, hearing and vision
services.
(i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (j) To ensure full access to the benefits set forth in this
Section, on and after January 1, 2022, the Illinois Department
shall ensure that provider and hospital reimbursements for
immunization as required under this Section are no lower than
70% of the median regional maximum administration fee for the State of Illinois as established
by the U.S. Department of Health and Human Services' Centers
for Medicare and Medicaid Services. (Source: P.A. 102-43, eff. 7-6-21.)
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(305 ILCS 5/5-20)
Sec. 5-20. Electronic health care card. By December 31, 1994, the
Illinois Department may develop and implement by rule an electronic health
information system to process claims electronically and to electronically store
Medicare and Medicaid patient records, medical histories, and billing
information. The Illinois Department may issue each Medicare and Medicaid
recipient a health card containing electronically coded information that will
access the system, verify their Medicare or Medicaid status, and display how
much the patient must pay in deductibles or copayments for a medical procedure.
The Illinois Department may also develop safeguards to protect recipients'
health information from misuse or unauthorized disclosure.
On or before July 1, 2011, the Department shall cease issuing monthly MediPlan cards and shall instead issue permanent or semi-permanent member cards to individuals enrolled for medical assistance. Furthermore, the Department may employ any reasonable means by which providers may verify an individual's eligibility for medical assistance in place of MediPlan cards. (Source: P.A. 96-940, eff. 1-1-11.)
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(305 ILCS 5/5-21)
Sec. 5-21. Immunization. By July 1, 1994, the Illinois Department shall,
in cooperation with the Department of Public Health, establish and implement a
pilot program that will provide immunization services for children on a walk-in
basis at local public aid offices. The Director shall determine the number and
location of the local public aid offices that will participate in the pilot
program. The Illinois Department shall submit a report on the effectiveness
of the program to the General Assembly on or before December 31, 1995.
The Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Human Services, in
cooperation with the Department of Public Health, shall continue to implement
the pilot program after the effective date of this amendatory Act of 1996.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/5-22)
Sec. 5-22. (Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 96-1123, eff. 1-1-11.)
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(305 ILCS 5/5-23)
Sec. 5-23.
(Repealed).
(Source: P.A. 92-581, eff. 6-26-02. Repealed internally, eff. 7-1-03.)
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(305 ILCS 5/5-24)
Sec. 5-24. (Repealed).(Source: P.A. 97-689, eff. 6-14-12. Repealed internally, eff. 1-1-14.)
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(305 ILCS 5/5-25) Sec. 5-25. Pediatric asthma initiative. (a) During fiscal year 2006, the Department of Public Aid shall evaluate current standards of treatment of asthma for its beneficiaries. The review may include state-of-the-art programs in asthma disease management as well as evidence-based best practices for the early diagnosis, treatment, and control of asthma, particularly in children. The Department's review may include asthma disease management as one component of a comprehensive disease management model. The Department shall consult with the Department of Public Health and other State agencies, advocates, and providers in conducting this review. The Department's review shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The review shall also assess the available methods of implementing and funding asthma disease management and treatment within the Medicaid program. (b) After completing the review under subsection (a), the Department of Public Aid shall develop a pilot asthma disease management program. The pilot program shall be targeted to an area or areas with the highest prevalence of asthma.
The Department shall consult with the Department of Public Health and other State agencies, federal health agencies, experts in asthma and immunology, providers, and consumers in developing the pilot program. The pilot program shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The pilot program shall be subject to specific appropriations or budget savings derived from the program due to reduced asthma-related hospitalizations or emergency room visits.
(Source: P.A. 94-328, eff. 7-26-05.) |
(305 ILCS 5/5-26) Sec. 5-26. Federal Family Opportunity Act. (a) As used in this Section, "the federal Act" means the federal Family Opportunity Act, enacted as part of the Deficit Reduction Act of 2005.
(b) Subject to appropriations for program administration and services, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall implement the Medical Assistance provisions of the federal Act as soon as possible after the effective date of this amendatory Act of the 95th General Assembly. (c) As soon as possible after the effective date of this amendatory Act of the 95th General Assembly, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall take all necessary and appropriate steps to try to secure (i) any available federal funds for a demonstration project regarding home and community-based alternatives to psychiatric residential treatment facilities for children, as authorized by the federal Act, and (ii) the location in Illinois of a family-to-family health information center, as authorized by the federal Act.
(Source: P.A. 97-48, eff. 6-28-11.) |
(305 ILCS 5/5-27) Sec. 5-27. (Repealed).(Source: P.A. 96-1372, eff. 7-29-10. Repealed internally, eff. 1-1-11.) |
(305 ILCS 5/5-28) Sec. 5-28. Community transition resources. The Department of Healthcare and Family Services, in collaboration with all relevant agencies, shall develop a Community Transition Plan to allow nursing facility residents who are determined to be appropriate for transition to the community to access or acquire resources to support the transition. These strategies may include, but need not be limited to, enhancement of the Community Home Maintenance Allowance, retention of income from work, and incorporation of community transition services into existing home and community-based waiver programs.
(Source: P.A. 96-1372, eff. 7-29-10.) |
(305 ILCS 5/5-29) Sec. 5-29. Income Limits and Parental Responsibility. In light of the unprecedented fiscal crisis confronting the State, it is the intent of the General Assembly to explore whether the income limits and income counting methods established for children under the Covering ALL KIDS Health Insurance Act, pursuant to this amendatory Act of the 96th General Assembly, should apply to medical assistance programs available to children made eligible under the Illinois Public Aid Code, including through home and community based services waiver programs authorized under Section 1915(c) of the Social Security Act, where parental income is currently not considered in determining a child's eligibility for medical assistance. The Department of Healthcare and Family Services is hereby directed, with the participation of the Department of Human Services and stakeholders, to conduct an analysis of these programs to determine parental cost sharing opportunities, how these opportunities may impact the children currently in the programs, waivers and on the waiting list, and any other factors which may increase efficiencies and decrease State costs. The Department is further directed to review how services under these programs and waivers may be provided by the use of a combination of skilled, unskilled, and uncompensated care and to advise as to what revisions to the Nurse Practice Act, and Acts regulating other relevant professions, are necessary to accomplish this combination of care. The Department shall submit a written analysis on the children's programs and waivers as part of the Department's annual Medicaid reports due to the General Assembly in 2011 and 2012.
(Source: P.A. 96-1501, eff. 1-25-11.) |
(305 ILCS 5/5-30) Sec. 5-30. Care coordination. (a) At least 50% of recipients eligible for comprehensive medical benefits in all medical assistance programs or other health benefit programs administered by the Department, including the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act, shall be enrolled in a care coordination program by no later than January 1, 2015. For purposes of this Section, "coordinated care" or "care coordination" means delivery systems where recipients will receive their care from providers who participate under contract in integrated delivery systems that are responsible for providing or arranging the majority of care, including primary care physician services, referrals from primary care physicians, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services. The Department shall designate or contract for such integrated delivery systems (i) to ensure enrollees have a choice of systems and of primary care providers within such systems; (ii) to ensure that enrollees receive quality care in a culturally and linguistically appropriate manner; and (iii) to ensure that coordinated care programs meet the diverse needs of enrollees with developmental, mental health, physical, and age-related disabilities. (b) Payment for such coordinated care shall be based on arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of primary care delivered through comprehensive medical homes, the use of electronic medical records, and the appropriate exchange of health information electronically made either on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements. (c) To qualify for compliance with this Section, the 50% goal shall be achieved by enrolling medical assistance enrollees from each medical assistance enrollment category, including parents, children, seniors, and people with disabilities to the extent that current State Medicaid payment laws would not limit federal matching funds for recipients in care coordination programs. In addition, services must be more comprehensively defined and more risk shall be assumed than in the Department's primary care case management program as of January 25, 2011 (the effective date of Public Act 96-1501). (d) The Department shall report to the General Assembly in a separate part of its annual medical assistance program report, beginning April, 2012 until April, 2016, on the progress and implementation of the care coordination program initiatives established by the provisions of Public Act 96-1501. The Department shall include in its April 2011 report a full analysis of federal laws or regulations regarding upper payment limitations to providers and the necessary revisions or adjustments in rate methodologies and payments to providers under this Code that would be necessary to implement coordinated care with full financial risk by a party other than the Department.
(e) Integrated Care Program for individuals with chronic mental health conditions. (1) The Integrated Care Program shall encompass | ||
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(2) The Department may utilize and expand upon | ||
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(3) Payment for such coordinated care shall be based | ||
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(4) The Department shall examine whether chronic | ||
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(A) Improve the patient's overall mental health | ||
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(B) Lower costs in other aspects of the medical | ||
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(5) The Department shall work with the facilities and | ||
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(f) A hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as set forth in Section 5-30 of this Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of this Code for which it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital no later than 60 days after June 14, 2012 (the effective date of Public Act 97-689) or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care program. For purposes of this subsection, "Coordinated Care Participating Hospital" means a hospital that meets one of the following criteria: (1) The hospital has entered into a contract to | ||
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(2) The hospital has not been offered a contract by a | ||
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As used in this subsection (f), "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. (g) No later than August 1, 2013, the Department shall issue a purchase of care solicitation for Accountable Care Entities (ACE) to serve any children and parents or caretaker relatives of children eligible for medical assistance under this Article. An ACE may be a single corporate structure or a network of providers organized through contractual relationships with a single corporate entity. The solicitation shall require that: (1) An ACE operating in Cook County be capable of | ||
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(2) An ACE must include at a minimum the following | ||
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(3) An ACE shall have a governance structure that | ||
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(4) An ACE must be an integrated delivery system, | ||
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(5) An ACE must be capable of providing both care | ||
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(6) In the first 18 months of operation, unless the | ||
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(7) In months 19 through 36 of operation, unless the | ||
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(8) In the fourth and subsequent years of operation, | ||
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The Department shall allow potential ACE entities 5 months from the date of the posting of the solicitation to submit proposals. After the solicitation is released, in addition to the MCO rate development data available on the Department's website, subject to federal and State confidentiality and privacy laws and regulations, the Department shall provide 2 years of de-identified summary service data on the targeted population, split between children and adults, showing the historical type and volume of services received and the cost of those services to those potential bidders that sign a data use agreement. The Department may add up to 2 non-state government employees with expertise in creating integrated delivery systems to its review team for the purchase of care solicitation described in this subsection. Any such individuals must sign a no-conflict disclosure and confidentiality agreement and agree to act in accordance with all applicable State laws. During the first 2 years of an ACE's operation, the Department shall provide claims data to the ACE on its enrollees on a periodic basis no less frequently than monthly. Nothing in this subsection shall be construed to limit the Department's mandate to enroll 50% of its beneficiaries into care coordination systems by January 1, 2015, using all available care coordination delivery systems, including Care Coordination Entities (CCE), MCCNs, or MCOs, nor be construed to affect the current CCEs, MCCNs, and MCOs selected to serve seniors and persons with disabilities prior to that date. Nothing in this subsection precludes the Department from considering future proposals for new ACEs or expansion of existing ACEs at the discretion of the Department. (h) Department contracts with MCOs and other entities reimbursed by risk based capitation shall have a minimum medical loss ratio of 85%, shall require the entity to establish an appeals and grievances process for consumers and providers, and shall require the entity to provide a quality assurance and utilization review program. Entities contracted with the Department to coordinate healthcare regardless of risk shall be measured utilizing the same quality metrics. The quality metrics may be population specific. Any contracted entity serving at least 5,000 seniors or people with disabilities or 15,000 individuals in other populations covered by the Medical Assistance Program that has been receiving full-risk capitation for a year shall be accredited by a national accreditation organization authorized by the Department within 2 years after the date it is eligible to become accredited. The requirements of this subsection shall apply to contracts with MCOs entered into or renewed or extended after June 1, 2013. (h-5) The Department shall monitor and enforce compliance by MCOs with agreements they have entered into with providers on issues that include, but are not limited to, timeliness of payment, payment rates, and processes for obtaining prior approval. The Department may impose sanctions on MCOs for violating provisions of those agreements that include, but are not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. As used in this subsection (h-5), "MCO" has the meaning ascribed to that term in Section 5-30.1 of this Code. (i) Unless otherwise required by federal law, Medicaid Managed Care Entities and their respective business associates shall not disclose, directly or indirectly, including by sending a bill or explanation of benefits, information concerning the sensitive health services received by enrollees of the Medicaid Managed Care Entity to any person other than covered entities and business associates, which may receive, use, and further disclose such information solely for the purposes permitted under applicable federal and State laws and regulations if such use and further disclosure satisfies all applicable requirements of such laws and regulations. The Medicaid Managed Care Entity or its respective business associates may disclose information concerning the sensitive health services if the enrollee who received the sensitive health services requests the information from the Medicaid Managed Care Entity or its respective business associates and authorized the sending of a bill or explanation of benefits. Communications including, but not limited to, statements of care received or appointment reminders either directly or indirectly to the enrollee from the health care provider, health care professional, and care coordinators, remain permissible. Medicaid Managed Care Entities or their respective business associates may communicate directly with their enrollees regarding care coordination activities for those enrollees. For the purposes of this subsection, the term "Medicaid Managed Care Entity" includes Care Coordination Entities, Accountable Care Entities, Managed Care Organizations, and Managed Care Community Networks. For purposes of this subsection, the term "sensitive health services" means mental health services, substance abuse treatment services, reproductive health services, family planning services, services for sexually transmitted infections and sexually transmitted diseases, and services for sexual assault or domestic abuse. Services include prevention, screening, consultation, examination, treatment, or follow-up. For purposes of this subsection, "business associate", "covered entity", "disclosure", and "use" have the meanings ascribed to those terms in 45 CFR 160.103. Nothing in this subsection shall be construed to relieve a Medicaid Managed Care Entity or the Department of any duty to report incidents of sexually transmitted infections to the Department of Public Health or to the local board of health in accordance with regulations adopted under a statute or ordinance or to report incidents of sexually transmitted infections as necessary to comply with the requirements under Section 5 of the Abused and Neglected Child Reporting Act or as otherwise required by State or federal law. The Department shall create policy in order to implement the requirements in this subsection. (j) Managed Care Entities (MCEs), including MCOs and all other care coordination organizations, shall develop and maintain a written language access policy that sets forth the standards, guidelines, and operational plan to ensure language appropriate services and that is consistent with the standard of meaningful access for populations with limited English proficiency. The language access policy shall describe how the MCEs will provide all of the following required services: (1) Translation (the written replacement of text from | ||
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(2) Qualified interpreter services (the oral | ||
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(3) Staff training on the language access policy, | ||
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(4) Data tracking that identifies the language need. (5) Notification to participants on the availability | ||
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(k) The Department shall actively monitor the contractual relationship between Managed Care Organizations (MCOs) and any dental administrator contracted by an MCO to provide dental services. The Department shall adopt appropriate dental Healthcare Effectiveness Data and Information Set (HEDIS) measures and shall include the Annual Dental Visit (ADV) HEDIS measure in its Health Plan Comparison Tool and Illinois Medicaid Plan Report Card that is available on the Department's website for enrolled individuals. The Department shall collect from each MCO specific information about the types of contracted, broad-based care coordination occurring between the MCO and any dental administrator, including, but not limited to, pregnant women and diabetic patients in need of oral care. (Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. 6-4-18.) |
(305 ILCS 5/5-30.1) (Text of Section from P.A. 103-593) Sec. 5-30.1. Managed care protections. (a) As used in this Section: "Managed care organization" or "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. "Emergency services" means health care items and services, including inpatient and outpatient hospital services, furnished or required to evaluate and stabilize an emergency medical condition. "Emergency services" include inpatient stabilization services furnished during the inpatient stabilization period. "Emergency services" do not include post-stabilization medical services. "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, regardless of the final diagnosis given, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual (or, with | ||
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(2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) inadequately controlled pain; or (5) with respect to a pregnant woman who is having | ||
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(A) inadequate time to complete a safe transfer | ||
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(B) a transfer to another hospital may pose a | ||
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"Emergency medical screening examination" means a medical screening examination and evaluation by a physician licensed to practice medicine in all its branches or, to the extent permitted by applicable laws, by other appropriately licensed personnel under the supervision of or in collaboration with a physician licensed to practice medicine in all its branches to determine whether the need for emergency services exists. "Health care services" mean any medical or behavioral health services covered under the medical assistance program that are subject to review under a service authorization program. "Inpatient stabilization period" means the initial 72 hours of inpatient stabilization services, beginning from the date and time of the order for inpatient admission to the hospital. "Inpatient stabilization services" mean emergency services furnished in the inpatient setting at a hospital pursuant to an order for inpatient admission by a physician or other qualified practitioner who has admitting privileges at the hospital, as permitted by State law, to stabilize an emergency medical condition following an emergency medical screening examination. "Post-stabilization medical services" means health care services provided to an enrollee that are furnished in a hospital by a provider that is qualified to furnish such services and determined to be medically necessary by the provider and directly related to the emergency medical condition following stabilization. "Provider" means a facility or individual who is actively enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State. "Service authorization determination" means a decision made by a service authorization program in advance of, concurrent to, or after the provision of a health care service to approve, change the level of care, partially deny, deny, or otherwise limit coverage and reimbursement for a health care service upon review of a service authorization request. "Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted by an MCO, or its contracted utilization review organization, including, but not limited to, prior authorization, prior approval, pre-certification, concurrent review, retrospective review, or certification of admission, of health care services provided in the inpatient or outpatient hospital setting. "Service authorization request" means a request by a provider to a service authorization program to determine whether a health care service meets the reimbursement eligibility requirements for medically necessary, clinically appropriate care, resulting in the issuance of a service authorization determination. "Utilization review organization" or "URO" means an MCO's utilization review department or a peer review organization or quality improvement organization that contracts with an MCO to administer a service authorization program and make service authorization determinations. (b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act. (c) An MCO shall pay any provider of emergency services, including for inpatient stabilization services provided during the inpatient stabilization period, that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates. (d) (Blank). (e) Notwithstanding any other provision of law, the following requirements apply to MCOs in determining payment for all emergency services, including inpatient stabilization services provided during the inpatient stabilization period: (1) The MCO shall not impose any service | ||
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(A) Notification period: Hospitals shall notify | ||
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(B) If the admitting hospital complies with the | ||
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(C) Coverage for services provided during the | ||
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(2) The MCO shall cover emergency services provided | ||
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(3) The MCO shall have no obligation to cover | ||
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(4) The MCO shall not condition coverage for | ||
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(5) The determination of the attending emergency | ||
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(6) The MCO's financial responsibility for | ||
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(A) a plan physician with privileges at the | ||
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(B) a plan physician assumes responsibility for | ||
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(C) a contracting entity representative and the | ||
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(D) the enrollee is discharged. (e-5) An MCO shall pay for all post-stabilization medical services as a covered service in any of the following situations: (1) the MCO or its URO authorized such services; (2) such services were administered to maintain the | ||
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(3) the MCO or its URO did not respond to a request | ||
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(4) the MCO or its URO could not be contacted; or (5) the MCO or its URO and the treating provider, if | ||
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(f) Network adequacy and transparency. (1) The Department shall: (A) ensure that an adequate provider network is | ||
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(B) publicly release an explanation of its | ||
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(C) periodically ensure that an MCO continues to | ||
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(D) require MCOs, including Medicaid Managed Care | ||
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(E) require MCOs to ensure that any | ||
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(F) require MCOs, including Medicaid Managed Care | ||
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(2) Each MCO shall confirm its receipt of information | ||
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(g) Timely payment of claims. (1) The MCO shall pay a claim within 30 days of | ||
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(2) The MCO shall notify the billing party of its | ||
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(3) The MCO shall pay a penalty that is at least | ||
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(A) When an MCO is required to pay a timely | ||
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(B) Such payments shall be reported separately | ||
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(4)(A) The Department shall require MCOs to expedite | ||
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(B) Compliance with the expedited provider | ||
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(C) The Department shall share at least monthly its | ||
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(g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers: (1) in no instance shall a medically necessary | ||
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(2) the Department shall, by December 31, 2016, adopt | ||
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(A) such medically necessary covered services | ||
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(B) such policies and procedures shall be | ||
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(C) such rules shall be published for a review | ||
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The rules on payment resolutions shall include, but | ||
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(A) the extension of the timely filing period; (B) retroactive prior authorizations; and (C) guaranteed minimum payment rate of no less | ||
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The rules shall be applicable for both MCO coverage | ||
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If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements. (g-6) MCO Performance Metrics Report. (1) The Department shall publish, on at least a | ||
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(A) claims payment, including timeliness and | ||
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(B) prior authorizations; (C) grievance and appeals; (D) utilization statistics; (E) provider disputes; (F) provider credentialing; and (G) member and provider customer service. (2) The Department shall ensure that the metrics | ||
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(3) The metrics shall be developed in consultation | ||
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(4) Metrics shall be defined and incorporated into | ||
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(g-7) MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to Public Act 100-580, the Department shall post an analysis of MCO claims processing and payment performance on its website every 6 months. Such analysis shall include a review and evaluation of a representative sample of hospital claims that are rejected and denied for clean and unclean claims and the top 5 reasons for such actions and timeliness of claims adjudication, which identifies the percentage of claims adjudicated within 30, 60, 90, and over 90 days, and the dollar amounts associated with those claims. (g-8) Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO. An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees. Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process. Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute. The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination. Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed. Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy. The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process. Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing. (g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following: (A) Premium revenue, with appropriate adjustments. (B) Benefit expense, setting forth the aggregate | ||
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(i) Direct paid claims. (ii) Subcapitation payments. (iii) Other claim payments. (iv) Direct reserves. (v) Gross recoveries. (vi) Expenses for activities that improve health | ||
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(2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department. (g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of: (A) The execution date of a network participation | ||
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(B) The date the provider or its representative | ||
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(C) The provider effective date contained within the | ||
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(2) The standardized roster form may be submitted to the MCO at the same time that the provider submits an enrollment application to the Department through IMPACT. (3) By October 1, 2019, the Department shall require all MCOs to update their provider directory with information for new practitioners of existing contracted providers within 30 days of receipt of a complete and accurate standardized roster template in the format approved by the Department provided that the provider is effective in the Department's provider enrollment subsystem within the IMPACT system. Such provider directory shall be readily accessible for purposes of selecting an approved health care provider and comply with all other federal and State requirements. (g-11) The Department shall work with relevant stakeholders on the development of operational guidelines to enhance and improve operational performance of Illinois' Medicaid managed care program, including, but not limited to, improving provider billing practices, reducing claim rejections and inappropriate payment denials, and standardizing processes, procedures, definitions, and response timelines, with the goal of reducing provider and MCO administrative burdens and conflict. The Department shall include a report on the progress of these program improvements and other topics in its Fiscal Year 2020 annual report to the General Assembly. (g-12) Notwithstanding any other provision of law, if the Department or an MCO requires submission of a claim for payment in a non-electronic format, a provider shall always be afforded a period of no less than 90 business days, as a correction period, following any notification of rejection by either the Department or the MCO to correct errors or omissions in the original submission. Under no circumstances, either by an MCO or under the State's fee-for-service system, shall a provider be denied payment for failure to comply with any timely submission requirements under this Code or under any existing contract, unless the non-electronic format claim submission occurs after the initial 180 days following the latest date of service on the claim, or after the 90 business days correction period following notification to the provider of rejection or denial of payment. (g-13) Utilization Review Standardization and Transparency. (1) To ensure greater standardization and | ||
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(2) Prior to July 1, 2025, the Department shall in | ||
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(A) guidelines related to the publication of MCO | ||
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(B) procedures that, due to medical complexity, | ||
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(C) standardization of administrative forms used | ||
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(D) limitations on second or subsequent medical | ||
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(E) standardization of peer-to-peer processes and | ||
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(F) defined criteria for urgent and standard | ||
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(G) standardized criteria for service | ||
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(3) The Department shall expand the scope of the | ||
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(A) an analysis of the Medicaid MCO's compliance | ||
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(B) an analysis that compares and contrasts the | ||
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(C) an analysis, for each Medicaid MCO, of the | ||
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(D) provide a written report to the General | ||
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(h) The Department shall not expand mandatory MCO enrollment into new counties beyond those counties already designated by the Department as of June 1, 2014 for the individuals whose eligibility for medical assistance is not the seniors or people with disabilities population until the Department provides an opportunity for accountable care entities and MCOs to participate in such newly designated counties. (h-5) Leading indicator data sharing. By January 1, 2024, the Department shall obtain input from the Department of Human Services, the Department of Juvenile Justice, the Department of Children and Family Services, the State Board of Education, managed care organizations, providers, and clinical experts to identify and analyze key indicators from assessments and data sets available to the Department that can be shared with managed care organizations and similar care coordination entities contracted with the Department as leading indicators for elevated behavioral health crisis risk for children. To the extent permitted by State and federal law, the identified leading indicators shall be shared with managed care organizations and similar care coordination entities contracted with the Department within 6 months of identification for the purpose of improving care coordination with the early detection of elevated risk. Leading indicators shall be reassessed annually with stakeholder input. (i) The requirements of this Section apply to contracts with accountable care entities and MCOs entered into, amended, or renewed after June 16, 2014 (the effective date of Public Act 98-651). (j) Health care information released to managed care organizations. A health care provider shall release to a Medicaid managed care organization, upon request, and subject to the Health Insurance Portability and Accountability Act of 1996 and any other law applicable to the release of health information, the health care information of the MCO's enrollee, if the enrollee has completed and signed a general release form that grants to the health care provider permission to release the recipient's health care information to the recipient's insurance carrier. (k) The Department of Healthcare and Family Services, managed care organizations, a statewide organization representing hospitals, and a statewide organization representing safety-net hospitals shall explore ways to support billing departments in safety-net hospitals. (l) The requirements of this Section added by Public Act 102-4 shall apply to services provided on or after the first day of the month that begins 60 days after April 27, 2021 (the effective date of Public Act 102-4). (m) Except where otherwise expressly specified, the requirements of this Section added by this amendatory Act of the 103rd General Assembly shall apply to services provided on or after July 1, 2025. (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. 5-13-22; 103-546, eff. 8-11-23; 103-593, eff. 6-7-24.) (Text of Section from P.A. 103-885) Sec. 5-30.1. Managed care protections. (a) As used in this Section: "Managed care organization" or "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. "Emergency services" include: (1) emergency services, as defined by Section 10 of | ||
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(2) emergency medical screening examinations, as | ||
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(3) post-stabilization medical services, as defined | ||
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(4) emergency medical conditions, as defined by | ||
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(b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act. (c) An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates. (d) An MCO shall pay for all post-stabilization services as a covered service in any of the following situations: (1) the MCO authorized such services; (2) such services were administered to maintain the | ||
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(3) the MCO did not respond to a request to authorize | ||
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(4) the MCO could not be contacted; or (5) the MCO and the treating provider, if the | ||
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(e) The following requirements apply to MCOs in determining payment for all emergency services: (1) MCOs shall not impose any requirements for prior | ||
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(2) The MCO shall cover emergency services provided | ||
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(3) The MCO shall have no obligation to cover medical | ||
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(4) The MCO shall not condition coverage for | ||
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(5) The determination of the attending emergency | ||
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(6) The MCO's financial responsibility for | ||
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(A) a plan physician with privileges at the | ||
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(B) a plan physician assumes responsibility for | ||
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(C) a contracting entity representative and the | ||
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(D) the enrollee is discharged. (f) Network adequacy and transparency. (1) The Department shall: (A) ensure that an adequate provider network is | ||
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(B) publicly release an explanation of its | ||
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(C) periodically ensure that an MCO continues to | ||
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(D) require MCOs, including Medicaid Managed Care | ||
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(E) require MCOs to ensure that any | ||
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(F) require MCOs, including Medicaid Managed Care | ||
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(2) Each MCO shall confirm its receipt of information | ||
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(g) Timely payment of claims. (1) The MCO shall pay a claim within 30 days of | ||
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(2) The MCO shall notify the billing party of its | ||
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(3) The MCO shall pay a penalty that is at least | ||
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(A) When an MCO is required to pay a timely | ||
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(B) Such payments shall be reported separately | ||
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(4)(A) The Department shall require MCOs to expedite | ||
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(B) Compliance with the expedited provider | ||
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(C) The Department shall share at least monthly its | ||
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(g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers: (1) in no instance shall a medically necessary | ||
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(2) the Department shall, by December 31, 2016, adopt | ||
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(A) such medically necessary covered services | ||
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(B) such policies and procedures shall be | ||
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(C) such rules shall be published for a review | ||
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The rules on payment resolutions shall include, but | ||
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(A) the extension of the timely filing period; (B) retroactive prior authorizations; and (C) guaranteed minimum payment rate of no less | ||
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The rules shall be applicable for both MCO coverage | ||
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If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements. (g-6) MCO Performance Metrics Report. (1) The Department shall publish, on at least a | ||
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(A) claims payment, including timeliness and | ||
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(B) prior authorizations; (C) grievance and appeals; (D) utilization statistics; (E) provider disputes; (F) provider credentialing; and (G) member and provider customer service. (2) The Department shall ensure that the metrics | ||
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(3) The metrics shall be developed in consultation | ||
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(4) Metrics shall be defined and incorporated into | ||
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(g-7) MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to Public Act 100-580, the Department shall post an analysis of MCO claims processing and payment performance on its website every 6 months. Such analysis shall include a review and evaluation of a representative sample of hospital claims that are rejected and denied for clean and unclean claims and the top 5 reasons for such actions and timeliness of claims adjudication, which identifies the percentage of claims adjudicated within 30, 60, 90, and over 90 days, and the dollar amounts associated with those claims. (g-8) Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO. An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees. Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process. Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute. The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination. Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed. Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy. The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process. Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing. (g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following: (A) Premium revenue, with appropriate adjustments. (B) Benefit expense, setting forth the aggregate | ||
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(i) Direct paid claims. (ii) Subcapitation payments. (iii) Other claim payments. (iv) Direct reserves. (v) Gross recoveries. (vi) Expenses for activities that improve health | ||
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(2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department. (g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of: (A) The execution date of a network participation | ||
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(B) The date the provider or its representative | ||
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(C) The provider effective date contained within the | ||
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(2) The standardized roster form may be submitted to the MCO at the same time that the provider submits an enrollment application to the Department through IMPACT. (3) By October 1, 2019, the Department shall require all MCOs to update their provider directory with information for new practitioners of existing contracted providers within 30 days of receipt of a complete and accurate standardized roster template in the format approved by the Department provided that the provider is effective in the Department's provider enrollment subsystem within the IMPACT system. Such provider directory shall be readily accessible for purposes of selecting an approved health care provider and comply with all other federal and State requirements. (g-11) The Department shall work with relevant stakeholders on the development of operational guidelines to enhance and improve operational performance of Illinois' Medicaid managed care program, including, but not limited to, improving provider billing practices, reducing claim rejections and inappropriate payment denials, and standardizing processes, procedures, definitions, and response timelines, with the goal of reducing provider and MCO administrative burdens and conflict. The Department shall include a report on the progress of these program improvements and other topics in its Fiscal Year 2020 annual report to the General Assembly. (g-12) Notwithstanding any other provision of law, if the Department or an MCO requires submission of a claim for payment in a non-electronic format, a provider shall always be afforded a period of no less than 90 business days, as a correction period, following any notification of rejection by either the Department or the MCO to correct errors or omissions in the original submission. Under no circumstances, either by an MCO or under the State's fee-for-service system, shall a provider be denied payment for failure to comply with any timely submission requirements under this Code or under any existing contract, unless the non-electronic format claim submission occurs after the initial 180 days following the latest date of service on the claim, or after the 90 business days correction period following notification to the provider of rejection or denial of payment. (h) The Department shall not expand mandatory MCO enrollment into new counties beyond those counties already designated by the Department as of June 1, 2014 for the individuals whose eligibility for medical assistance is not the seniors or people with disabilities population until the Department provides an opportunity for accountable care entities and MCOs to participate in such newly designated counties. (h-5) Leading indicator data sharing. By January 1, 2024, the Department shall obtain input from the Department of Human Services, the Department of Juvenile Justice, the Department of Children and Family Services, the State Board of Education, managed care organizations, providers, and clinical experts to identify and analyze key indicators and data elements that can be used in an analysis of lead indicators from assessments and data sets available to the Department that can be shared with managed care organizations and similar care coordination entities contracted with the Department as leading indicators for elevated behavioral health crisis risk for children, including data sets such as the Illinois Medicaid Comprehensive Assessment of Needs and Strengths (IM-CANS), calls made to the State's Crisis and Referral Entry Services (CARES) hotline, health services information from Health and Human Services Innovators, or other data sets that may include key indicators. The workgroup shall complete its recommendations for leading indicator data elements on or before September 1, 2024. To the extent permitted by State and federal law, the identified leading indicators shall be shared with managed care organizations and similar care coordination entities contracted with the Department on or before December 1, 2024 for the purpose of improving care coordination with the early detection of elevated risk. Leading indicators shall be reassessed annually with stakeholder input. The Department shall implement guidance to managed care organizations and similar care coordination entities contracted with the Department, so that the managed care organizations and care coordination entities respond to lead indicators with services and interventions that are designed to help stabilize the child. (i) The requirements of this Section apply to contracts with accountable care entities and MCOs entered into, amended, or renewed after June 16, 2014 (the effective date of Public Act 98-651). (j) Health care information released to managed care organizations. A health care provider shall release to a Medicaid managed care organization, upon request, and subject to the Health Insurance Portability and Accountability Act of 1996 and any other law applicable to the release of health information, the health care information of the MCO's enrollee, if the enrollee has completed and signed a general release form that grants to the health care provider permission to release the recipient's health care information to the recipient's insurance carrier. (k) The Department of Healthcare and Family Services, managed care organizations, a statewide organization representing hospitals, and a statewide organization representing safety-net hospitals shall explore ways to support billing departments in safety-net hospitals. (l) The requirements of this Section added by Public Act 102-4 shall apply to services provided on or after the first day of the month that begins 60 days after April 27, 2021 (the effective date of Public Act 102-4). (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. 5-13-22; 103-546, eff. 8-11-23; 103-885, eff. 8-9-24.) |
(305 ILCS 5/5-30.2) Sec. 5-30.2. Monthly reports; managed care enrollment. (a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a Care Coordination Entity (CCE) contracted by the Department. (b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition, as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department. As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department: (1) Total enrollment. (2) The number of persons enrolled in the medical | ||
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(3) The number of children enrolled. (4) The number of parents and caretakers of minor | ||
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(5) The number of women enrolled on the basis of | ||
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(6) The number of seniors enrolled. (7) The number of persons enrolled on the basis of | ||
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(c) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section. (d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year. (e) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages. (f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system.
(Source: P.A. 99-86, eff. 7-21-15.) |
(305 ILCS 5/5-30.3) Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care. (a) Definitions. As used in this Section: "Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities. "Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures. "Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format. "Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan. "Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers. "Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals. "Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services. "Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated. "Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code. (b) Provider directory transparency. (1) Each Medicaid Managed Care Entity shall: (A) Make available on the entity's website a | ||
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(B) Make provider directories publicly accessible | ||
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(C) Comply with all federal and State statutes | ||
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(D) Request, at least annually, provider office | ||
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(i) Health care professionals, including | ||
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(ii) Hospitals. (iii) Facilities, other than hospitals. (iv) Pharmacies, other than hospitals. (v) Durable medical equipment suppliers, | ||
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Medicaid Managed Care Entities shall publish the | ||
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(E) Confirm with the Medicaid Managed Care | ||
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(F) Ensure that in situations in which a Medicaid | ||
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(G) Conspicuously display an e-mail address and a | ||
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(2) The Department shall: (A) Regularly monitor Medicaid Managed Care | ||
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(B) Require that the client enrollment services | ||
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(C) Ensure that each Medicaid Managed Care Entity | ||
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(D) Ensure that the client enrollment services | ||
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(E) Require the client enrollment services broker | ||
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(c) Formulary transparency. (1) Medicaid Managed Care Entities shall publish on | ||
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(2) Medicaid Managed Care Entities shall provide | ||
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(3) Electronic and print formularies shall display: (A) the medications covered (both generic and | ||
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(B) if the medication is preferred or not | ||
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(C) what tier each medication is in and the | ||
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(D) any utilization controls including, but not | ||
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(E) any required cost-sharing; (F) a glossary of key terms and explanation of | ||
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(G) a key or legend for all utilization controls | ||
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(H) directions explaining the process or | ||
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(4) Each Medicaid Managed Care Entity shall display | ||
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(5) Each Medicaid Managed Care Entity shall include a | ||
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(6) The client enrollment services broker's website | ||
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(d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action. (e) Medicaid redetermination information.
The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process. (f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to: (1) a basic description of the role of care | ||
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(2) how a Medicaid enrollee may request care | ||
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(g) Consumer quality comparison tool. (1) The Department shall create a consumer quality | ||
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(2) At a minimum, a printed version of the consumer | ||
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(A) Display Medicaid Managed Care Entities' | ||
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(i) Healthcare Effectiveness Data and | ||
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(ii) Core Set of Children's Health Care | ||
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(iii) Adult Core Set measures. (iv) Consumer Assessment of Healthcare | ||
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(v) Additional performance measures the | ||
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(B) Use a quality rating system developed by the | ||
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(C) Be customized to reflect the specific | ||
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(D) Include contact information for the client | ||
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(E) Include guiding questions designed to assist | ||
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(3) At a minimum, the online version of the consumer | ||
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(A) Display Medicaid Managed Care Entities' | ||
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(B) Display Medicaid Managed Care Entities' | ||
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(C) Use a quality rating system developed by the | ||
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(D) Include the specific Medicaid Managed Care | ||
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(E) Include a sort function to view Medicaid | ||
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(F) Include contact information for the client | ||
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(G) Include guiding questions designed to assist | ||
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(H) Prominently display current notice of quality | ||
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(4) The online version of the consumer quality | ||
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(5) In the development of the consumer quality | ||
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(A) The standardized data sets and surveys, | ||
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(B) The format and presentation of the consumer | ||
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(C) The methods undertaken by the Department to | ||
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(6) The Department shall review and update as | ||
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(7) The Department shall ensure that the consumer | ||
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(h)
The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.) |
(305 ILCS 5/5-30.4) Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care.
(Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.) |
(305 ILCS 5/5-30.5) Sec. 5-30.5. Managed care; automatic assignment. The
Department shall, within a reasonable period of time after
relevant data from managed care entities has been collected and
analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and
implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes
into account quality scores and other operational proficiency
criteria developed, defined, and adopted by the Department, to
automatically assign Medicaid enrollees served under the
Family Health Plan and the Integrated Care Program and those
Medicaid enrollees eligible for medical assistance pursuant to
the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable
Care Entities, Managed Care Community Networks, and Managed
Care Organizations. The quality metrics used shall be
measurable for all entities. The algorithm shall not use the
quality and proficiency metrics to reassign enrollees out of
any plan in which they are enrolled at the time and shall only
be used if the client has not voluntarily selected a primary
care physician and a managed care entity or care coordination
entity. Clients shall have one opportunity within 90 calendar
days after auto-assignment by algorithm to select a different
managed care entity. The algorithm developed and implemented
shall favor assignment into managed care entities with the
highest quality scores and levels of compliance with the
operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.
(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.) |
(305 ILCS 5/5-30.6) Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code. (a) Application. (1) This Section does not apply to the State of | ||
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(2) This Section does not apply to Medicare-Medicaid | ||
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(b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency.
(Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.) |
(305 ILCS 5/5-30.7) Sec. 5-30.7. Encounter data guidelines; provider fee schedule. (a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices. (b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.
(Source: P.A. 100-580, eff. 3-12-18.) |
(305 ILCS 5/5-30.8) Sec. 5-30.8. Managed care organization rate transparency. (a) For the establishment of managed care
organization (MCO) capitation base rate payments from the State,
including, but not limited to: (i) hospital fee schedule
reforms and updates, (ii) rates related to a single
State-mandated preferred drug list, (iii) rate updates related
to the State's preferred drug list, (iv) inclusion of coverage
for children with special needs, (v) inclusion of coverage for
children within the child welfare system, (vi) annual MCO
capitation rates, and (vii) any retroactive provider fee
schedule adjustments or other changes required by legislation
or other actions, the Department of Healthcare and Family
Services shall implement a capitation base rate setting process beginning
on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following
elements of transparency: (1) The Department shall include participating | ||
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(2) The Department shall not limit the number of | ||
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(3) The Department and its contracted actuary shall | ||
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(4) (Blank). (4.5) Effective for calendar year 2024, a quality | ||
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(5) Upon request, the Department shall | ||
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(b) For the development of capitation base rates for new capitation rate years: (1) The Department shall take into account emerging | ||
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(2) No later than January 1 of each year, the | ||
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(A) An initial meeting for the Department to | ||
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(B) A draft rate meeting after the Department | ||
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(3) Prior to the submission of final capitation | ||
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(c) For the development of capitation base rates reflecting policy changes: (1) Unless contrary to federal law and regulation, | ||
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(2) No later than 60 days after the effective | ||
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(3) No later than 60 days after the effective date of | ||
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(4) No later than 60 days after the effective | ||
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(d) For the development of capitation base rates for retroactive policy or
fee schedule changes: (1) The Department shall meet with the MCOs regarding | ||
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(2) The Department shall meet with MCOs to review | ||
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(3) The Department shall provide the MCOs with draft | ||
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(4) The Department shall inform MCOs no less than | ||
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(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.
(Source: P.A. 103-102, eff. 1-1-24.) |
(305 ILCS 5/5-30.9) Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.
(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.) |
(305 ILCS 5/5-30.10) Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.
(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.) |
(305 ILCS 5/5-30.11) Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.
(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.) |
(305 ILCS 5/5-30.12) Sec. 5-30.12. Managed care claim rejection and denial management. (a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs: (1) The technology shall allow the Department to | ||
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(2) The technology shall create a single electronic | ||
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(3) The technology shall cause all HIPAA-compliant | ||
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(4) The technology shall give the Department the | ||
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(5) The technology shall allow the Department to | ||
| ||
(6) The technology shall send copies of all claims | ||
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(b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date. (c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline. MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs. (d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.
(Source: P.A. 101-209, eff. 8-5-19.) |
(305 ILCS 5/5-30.13)
Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information: (1) The administrative expenses paid to the Medicaid | ||
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(2) The amount of money the Medicaid managed care | ||
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(3) The amount of money the Medicaid managed care | ||
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(4) The amount of money the Medicaid managed care | ||
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(5) The proportion of minorities, people with | ||
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(6) Recommendations for increasing expenditures with | ||
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(7) A list of the types of services to which the | ||
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(8) The certifications the Medicaid managed care | ||
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(9) The point of contact for potential vendors | ||
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The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.
(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)
|
(305 ILCS 5/5-30.14)
Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists. (a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development. (b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls. (c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall: (A) convene and meet no less than once per calendar | ||
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(B) provide regular opportunities for public comment; | ||
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(C) comply with the provisions of the Open Meetings | ||
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All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act. (2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation: (A) one pharmacist licensed to practice pharmacy in | ||
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(B) 4 physicians, recommended by a statewide | ||
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(C) at least one clinician who specializes in the | ||
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(D) at least one clinician recommended by a | ||
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(E) one clinician representing the Illinois | ||
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(F) one licensed psychiatrist, recommended by a | ||
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One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation. Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department. A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products. (d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.
(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)
|
(305 ILCS 5/5-30.16) Sec. 5-30.16. Medicaid Business Opportunity Commission. (a) The Medicaid Business Opportunity Commission is
created within the Department of Healthcare and Family Services
to develop a program to support and grow minority, women, and persons with disability owned businesses. (b) The Commission shall consist of the following members: (1) Two members appointed by the Illinois Legislative | ||
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(2) Two members appointed by the Illinois Legislative | ||
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(3) Two members appointed by the Conference of Women | ||
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(4) Two members representing a statewide Medicaid | ||
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(5) One member representing the Department of | ||
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(6) Three members representing businesses currently | ||
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(7) One member representing the disability | ||
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(8) One member representing the Business Enterprise | ||
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget. (d) The members of the Commission shall receive no compensation for their services as members of the Commission. (e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission. (f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly. (g) The Commission shall: (1) Develop a recommendation on a Medicaid Business | ||
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(2) Make recommendations on the process by which | ||
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(3) Make a recommendation on whether to include not | ||
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(4) Make a recommendation on whether diverse staff | ||
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(5) Make a recommendation on whether a new platform | ||
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(6) Make a recommendation on the ongoing activity of | ||
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(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program. (i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.) |
(305 ILCS 5/5-30.17) Sec. 5-30.17. Medicaid Managed Care Oversight Commission. (a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program. (b) The Commission shall consist of the following members: (1) One member of the Senate, appointed by the | ||
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(2) One member of the House of Representatives, | ||
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(3) One member of the House of Representatives, | ||
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(4) One member of the Senate, appointed by the | ||
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(5) One member representing the Department of | ||
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(6) One member representing the Department of | ||
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(7) One member representing the Department of Human | ||
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(8) One member representing the Department of | ||
| ||
(9) One member of a statewide association | ||
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(10) One member of a statewide association | ||
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(11) Two academic experts on Medicaid managed care | ||
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(12) One member of a statewide association | ||
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(13) One member of a statewide association | ||
| ||
(14) Members representing Federally Qualified Health | ||
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(15) A member of a statewide association representing | ||
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget. (d) The members of the Commission shall receive no compensation for their services as members of the Commission. (e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly. (f) The Commission shall: (1) review data on health outcomes of Medicaid | ||
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(2) review current care coordination and case | ||
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(3) review and assess the appropriateness of | ||
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(4) review the Department's prior authorization and | ||
| ||
(5) review managed care performance in meeting | ||
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(6) review data on the effectiveness of | ||
| ||
(7) review member access to health care services in | ||
| ||
(8) review value-based and other alternative | ||
| ||
(9) review the compliance of all managed care | ||
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(10) produce an annual report detailing the | ||
| ||
(11) review provider availability and make | ||
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(12) review capacity for culturally competent | ||
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(13) review and recommend changes to the safety-net | ||
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(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing. (g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.) |
(305 ILCS 5/5-30.18) (Section scheduled to be repealed on December 31, 2030) Sec. 5-30.18. Service authorization program performance. (a) Definitions. As used in this Section: "Gold Card provider" means a provider identified by each Medicaid Managed Care Organization (MCO) as qualified under the guidelines outlined by the Department in accordance with subsection (c) and thereby granted a service authorization exemption when ordering a health care service. "Health care service" means any medical or behavioral health service covered under the medical assistance program that is rendered in the inpatient or outpatient hospital setting, including hospital-based clinics, and subject to review under a service authorization program. "Provider" means an individual actively enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State, and, as determined by the Department, may also include hospitals that submit service authorization requests. "Service authorization exemption" means an exception granted by a Medicaid MCO to a provider under which all service authorization requests for covered health care services, excluding pharmacy services and durable medical equipment, are automatically deemed to be medically necessary, clinically appropriate, and approved for reimbursement as ordered. "Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted in advance of, concurrent to, or after the provision of a health care service by a Medicaid MCO, either directly or through a contracted utilization review organization (URO), including, but not limited to, prior authorization, pre-certification, certification of admission, concurrent review, and retrospective review of health care services. "Service authorization request" means a request by a provider to a service authorization program to determine whether a health care service that is otherwise covered under the medical assistance program meets the reimbursement requirements established by the Medicaid MCO, or its contracted URO, for medically necessary, clinically appropriate care and to issue a service authorization determination. "Utilization review organization" or "URO" means a managed care organization or other entity that has established or administers one or more service authorization programs. (b) In consultation with the Medicaid MCOs, a statewide association representing managed care organizations, a statewide association representing the majority of Illinois hospitals, and a statewide association representing physicians, the Department shall in accordance with the Illinois Administrative Procedure Act, adopt administrative rules, consistent with this Section, to require each Medicaid MCO to identify Gold Card providers with such identification initially being effective for health care services provided on and after July 1, 2025. (c) The Department shall adopt rules, in accordance with the Illinois Administrative Procedure Act, to implement this Section that include, but are not limited to, the following provisions: (1) Require each Medicaid MCO to provide a service | ||
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(2) Require that service authorization exemptions be | ||
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(3) The service authorization exemption shall be | ||
| ||
(4) The provider shall be required to continue to | ||
| ||
(5) Require that each Medicaid MCO publish on its | ||
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(6) Require that no later than December 1 of each | ||
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(7) Require that each Medicaid MCO or its URO use the | ||
| ||
(8) Require each Medicaid MCO to provide the | ||
| ||
(A) The independent third-party URO shall issue a | ||
| ||
(B) The independent third-party URO shall not be | ||
| ||
(d) Each Medicaid MCO must have a standard method to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. (e) A service authorization program shall not deny, partially deny, reduce the level of care, or otherwise limit reimbursement to the rendering or supervising provider, including the rendering facility, for health care services ordered by a provider who qualifies for a service authorization exemption, except in cases of fraud. (f) This Section is repealed on December 31, 2030.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-30a) Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program: (1) Children who are authorized by the Department to | ||
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(2) Children made eligible for medical assistance | ||
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Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.
(Source: P.A. 100-990, eff. 1-1-19.) |
(305 ILCS 5/5-30b) Sec. 5-30b. Exemptions from managed care; ground ambulance services. Notwithstanding any other provision of law, beginning on the effective date of this amendatory Act of the 102nd General Assembly, the Department shall exempt ground ambulance services as described in subsections (c-1) and (c-2) of Section 5-4.2. These services shall continue to be paid under the State's traditional fee-for-service program.
(Source: P.A. 102-661, eff. 1-1-22.) |
(305 ILCS 5/5-30d) Sec. 5-30d. Increased funding for transportation services. Beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/5-31) Sec. 5-31. (Repealed).(Source: P.A. 98-104, eff. 7-22-13. Repealed by P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-32) Sec. 5-32. (Repealed).(Source: P.A. 98-104, eff. 7-22-13. Repealed by P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-33) Sec. 5-33. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.) |
(305 ILCS 5/5-34) Sec. 5-34. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.) |
(305 ILCS 5/5-35) Sec. 5-35. Personal needs allowance. For a person who is a resident in a facility licensed under the ID/DD Community Care Act, the Community-Integrated Living Arrangements Licensure and Certification Act, the Specialized Mental Health Rehabilitation Act of 2013, or the MC/DD Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the State shall pay an amount in addition to the minimum monthly personal needs allowance authorized under Section 1902(q) of Title XIX of the Social Security Act (42 U.S.C. 1396(q)) so that the person's total monthly personal needs allowance from both State and federal sources equals $60.
(Source: P.A. 100-23, eff. 7-6-17.) |
(305 ILCS 5/5-35.5) Sec. 5-35.5. Personal needs allowance; nursing home residents. Subject to federal approval, on and after January 1, 2024, for a person who is a resident in a facility licensed under the Nursing Home Care Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the monthly personal needs allowance shall be $60.(Source: P.A. 103-102, eff. 1-1-24.) |
(305 ILCS 5/5-36) Sec. 5-36. Pharmacy benefits. (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law. (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies: (A) the Department shall approve any contract between | ||
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(B) the Department's third-party administrator shall | ||
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(C) the Department's third-party administrator shall | ||
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(b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5). (b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code. (c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section. (d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department. (e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information: (1) whether the pharmacy benefit manager has a | ||
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(2) the percentage of claims payments made by the | ||
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(3) the aggregate amount of the fees or assessments | ||
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(4) the average annualized percentage of revenue | ||
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(5) the total number of prescriptions dispensed under | ||
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(6) the aggregate wholesale acquisition cost for | ||
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(7) the aggregate amount of administrative fees that | ||
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(8) for each MCO with which the pharmacy benefit | ||
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(9) for each MCO with which the pharmacy benefit | ||
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(10) any other information considered necessary by | ||
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(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable. (g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies. (h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider: (1) a provision prohibiting the provider from | ||
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(2) a provision that prohibits the provider from | ||
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(h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that: (1) imposes any fee, chargeback, or rate adjustment | ||
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(2) imposes any fee, chargeback, or rate adjustment | ||
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(3) prevents or interferes with an individual's | ||
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(4) excludes a 340B entity or 340B pharmacy from a | ||
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(5) prevents a 340B entity or 340B pharmacy from | ||
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(6) any other provision that discriminates against a | ||
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A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable. In this subsection (h-5): "340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program. "340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external. (i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager. (j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department. (k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22; 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-36.1) Sec. 5-36.1. Earned income for residents of community-integrated living arrangements. (a) Beginning no later than July 1, 2021, residents of facilities licensed under the Community-Integrated Living Arrangements Licensure and Certification Act who are determined to be eligible for medical assistance under this Code and who are enrolled in the State's home and community-based services waiver program for adults with developmental disabilities shall retain all earned income from employment or community day services activities. (b) No portion of earned income shall be applied toward the facilities rate reimbursement methodology. The Department of Human Services shall ensure the rates of payments paid to facilities under the Code are held harmless.
(Source: P.A. 102-343, eff. 8-13-21.) |
(305 ILCS 5/5-36.5)
Sec. 5-36.5. Education on mental health and substance use treatment services for children and young adults. The Department of Healthcare and Family Services shall develop a layman's guide to the mental health and substance use treatment services available in Illinois through the Medical Assistance Program and through the Family Support Program, or other publicly funded programs, similar to what Massachusetts developed, to help families understand what services are available to them when they have a child in need of treatment or support. The guide shall be in easy-to-understand language, be prominently available on the Department of Healthcare and Family Services' website, and be part of a statewide communications campaign to ensure families are aware of Family Support Program services. It shall briefly explain the service and whether it is covered by the Medical Assistance Program, the Family Support Program, or any other public funding source. Within one year after January 1, 2020 (the effective date of Public Act 101-461), the Department of Healthcare and Family Services shall complete this guide, have it available on its website, and launch the communications campaign.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)
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(305 ILCS 5/5-37) Sec. 5-37. Billing mechanism for preventive mental health services delivered to children. (a) The General Assembly finds: (1) It is common for children to have mental health | ||
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(2) The federal requirement that Medicaid-covered | ||
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(3) The Department of Healthcare and Family Services' | ||
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(b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20.) |
(305 ILCS 5/5-38) Sec. 5-38. Alignment of children's mental health treatment systems. The Governor's Office shall establish, convene, and lead a working group that includes the Director of Healthcare and Family Services, the Secretary of Human Services, the Director of Public Health, the Director of Children and Family Services, the Director of Juvenile Justice, the State Superintendent of Education, and the appropriate agency staff who will be responsible for implementation or oversight of reforms to children's behavioral health services. The working group shall meet at least quarterly to foster interagency collaboration and work toward the goal of aligning services and programs to begin to create a coordinated children's behavioral health system consistent with system of care principles that spans across State agencies, rather than separate siloed systems with different requirements, rates, and administrative processes and standards.
(Source: P.A. 101-461, eff. 1-1-20.) |
(305 ILCS 5/5-39) Sec. 5-39. Behavioral health services for children; diagnostic assessment system. Beginning on July 1, 2022, if it is necessary to provide a diagnostic code for behavioral health services for children ages 5 and under, providers shall utilize a developmentally appropriate and age-appropriate diagnostic assessment system, such as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC:0-5), for diagnosis and treatment planning. If necessary for billing purposes, the provider, managed care organization, or Department shall utilize the existing crosswalk tool to convert the developmentally appropriate and age-appropriate diagnosis code to the relevant code available in the State system. By no later than January 1, 2022, the Department shall make recommendations to the General Assembly on the resources needed to integrate developmentally appropriate and age-appropriate diagnostic codes into the State system.
(Source: P.A. 101-654, eff. 3-8-21.) |
(305 ILCS 5/5-40) Sec. 5-40. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the infant's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the infant's birth weight is below 1,500 | ||
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(B) the infant has a congenital or acquired | ||
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(C) the infant has infant hypoglycemia; (D) the infant has congenital heart disease; (E) the infant has had or will have an organ | ||
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(F) the infant has sepsis; or (G) the infant has any other serious congenital | ||
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(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the child's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the child has spinal muscular atrophy; (B) the child's birth weight was below 1,500 | ||
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(C) the child has had or will have an organ | ||
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(D) the child has a congenital or acquired | ||
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(c) Notwithstanding any other provision of this Act,
pasteurized donated human breast milk, which may include human
milk fortifiers if indicated by a prescribing licensed medical
practitioner, shall be covered under a health plan for persons
who are otherwise eligible for coverage under this Act if the
covered person is a child 12 months of age or older, a licensed
medical practitioner prescribes the milk for the covered
person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the child's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) the child has spinal muscular atrophy.
(Source: P.A. 101-511, eff. 1-1-20.) |
(305 ILCS 5/5-41) Sec. 5-41. Inpatient hospitalization for opioid-related overdose or withdrawal patients. Due to the disproportionately high opioid-related fatality rates among African Americans in under-resourced communities in Illinois, the lack of community resources, the comorbidities experienced by these patients, and the high rate of hospital inpatient recidivism associated with this population when improperly treated, the Department shall ensure that patients, whether enrolled under the Medical Assistance Fee For Service program or enrolled with a Medicaid Managed Care Organization, experiencing opioid-related overdose or withdrawal are admitted on an inpatient status and the provider shall be reimbursed accordingly, when deemed medically necessary, as determined by either the patient's primary care physician, or the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, using criteria established by the American Society of Addiction Medicine. If it is determined by the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, that a patient does not meet medical necessity criteria for the admission, then the patient may be treated via observation and the provider shall seek reimbursement accordingly. Nothing in this Section shall diminish the requirements of a provider to document medical necessity in the patient's record.
(Source: P.A. 102-43, eff. 7-6-21; 102-813, eff. 5-13-22.) |
(305 ILCS 5/5-42) Sec. 5-42. Tobacco cessation coverage; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for all tobacco cessation medications approved by the United States Food and Drug Administration, all individual and group tobacco cessation counseling services, and all telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline. The Department may adopt any rules necessary to implement this Section.
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/5-43) Sec. 5-43. Supports Waiver Program for Young Adults with Developmental Disabilities. (a) The Department of Human Services' Division of Developmental Disabilities, in partnership with the Department of Healthcare and Family Services and stakeholders, shall study the development and implementation of a supports waiver program for young adults with developmental disabilities. The Division shall explore the following components of a supports waiver program to determine what is most appropriate: (1) The age of individuals to be provided services in | ||
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(2) The number of individuals to be provided services | ||
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(3) The services to be provided in a waiver program. (4) The funding to be provided to individuals within | ||
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(5) The transition process to the Waiver for Adults | ||
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(6) The type of home and community-based services | ||
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(b) The Department of Human Services and the Department of Healthcare and Family Services are authorized to adopt and implement any rules necessary to study the supports waiver program. (c) Subject to appropriation, no later than January 1, 2024, the Department of Healthcare and Family Services shall apply to the federal Centers for Medicare and Medicaid Services for a supports waiver for young adults with developmental disabilities utilizing the information learned from the study under subsection (a).
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/5-44)
Sec. 5-44. Screening, Brief Intervention, and Referral to Treatment. As used in this Section, "SBIRT" means a comprehensive, integrated, public health approach to the delivery of early intervention and treatment
services for persons who are at risk of developing substance use disorders or have substance use disorders including, but not limited to, an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT services include all of the following: (1) Screening to quickly assess the severity of | ||
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(2) Brief intervention focused on increasing insight | ||
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(3) Referral to treatment provided to those | ||
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SBIRT services may include, but are not limited to, the following settings and programs: primary care centers, hospital emergency rooms, hospital in-patient units,
trauma centers, community behavioral health programs, and other community settings that provide opportunities for early intervention with at-risk substance users before more severe
consequences occur. The Department of Healthcare and Family Services shall develop and seek federal approval of a SBIRT benefit for which
qualified providers shall be reimbursed under the medical assistance program. In conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, the Department of Healthcare and
Family Services may develop a methodology and reimbursement rate for SBIRT services provided by qualified providers in approved
settings. For opioid specific SBIRT services provided in a hospital emergency department, the Department of Healthcare and
Family Services shall develop a bundled reimbursement
methodology and rate for a package of opioid treatment services, which include initiation of medication for the treatment of opioid use disorder in
the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services when necessary. This
package of opioid related services shall be billed on a separate claim and shall be reimbursed outside of the Enhanced Ambulatory Patient
Grouping system.
(Source: P.A. 102-598, eff. 1-1-22; 102-813, eff. 5-13-22.)
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(305 ILCS 5/5-45) Sec. 5-45. Reimbursement rates; substance use disorder
treatment providers and facilities. Beginning on July 1, 2022,
the Department of Human Services' Division of Substance Use
Prevention and Recovery in conjunction with the Department of
Healthcare and Family Services, shall provide for an increase
in reimbursement rates by way of an increase to existing rates of
47% for all community-based substance use disorder treatment
services, including, but not limited to, all of the following: (1) Admission and Discharge Assessment. (2) Level 1 (Individual). (3) Level 1 (Group). (4) Level 2 (Individual). (5) Level 2 (Group). (6) Psychiatric/Diagnostic. (7) Medication Monitoring (Individual). (8) Methadone as an Adjunct to Treatment. No existing or future reimbursement rates or add-ons shall be
reduced or changed to address the rate increase proposed under this Section.
The Department of Healthcare and Family Services shall immediately,
no later than 3 months following April 19, 2022 (the effective date of Public Act 102-699),
submit any necessary application to the federal Centers for Medicare
and Medicaid Services for a waiver or State Plan amendment to implement the requirements of this Section.
Beginning in State fiscal year 2023, and every State fiscal year thereafter,
reimbursement rates for those community-based substance use disorder
treatment services shall be adjusted upward by an amount equal
to the Consumer Price Index-U from the previous year, not to
exceed 2% in any State fiscal year. If there is a decrease in
the Consumer Price Index-U, rates shall remain unchanged for
that State fiscal year. The Department of Human Services shall adopt rules,
including emergency rules under Section 5-45.1 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section. As used in this Section, "consumer price index-u"
means the index published by the Bureau of Labor Statistics of
the United States Department of Labor that measures the average
change in prices of goods and services purchased by all urban
consumers, United States city average, all items, 1982-84 =
100.
(Source: P.A. 102-699, eff. 4-19-22; 103-154, eff. 6-30-23.) |
(305 ILCS 5/5-46) Sec. 5-46. General acute care hospitals. A general acute care hospital is authorized to file a notice with the Department of Public Health and the Health Facilities and Services Review Board to establish an acute mental illness category of service in accordance with the Illinois Health Facilities Planning Act and add authorized acute mental illness beds if the following conditions are met: (1) the general acute care hospital qualifies as a | ||
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(2) the notice seeks to establish no more than 24 | ||
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(3) the notice seeks to reduce the number of | ||
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(Source: P.A. 102-886, eff. 5-17-22; 103-154, eff. 6-30-23.) |
(305 ILCS 5/5-47) Sec. 5-47. Medicaid reimbursement rates; substance use disorder treatment providers and facilities. (a) Beginning on January 1, 2024, subject to federal approval, the Department of Healthcare and Family Services, in conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, shall provide a 30% increase in reimbursement rates for all Medicaid-covered ASAM Level 3 residential/inpatient substance use disorder treatment services. No existing or future reimbursement rates or add-ons shall be reduced or changed to address this proposed rate increase. No later than 3 months after June 16, 2023 (the effective date of Public Act 103-102), the Department of Healthcare and Family Services shall submit any necessary application to the federal Centers for Medicare and Medicaid Services to implement the requirements of this Section. (a-5) Beginning in State fiscal year 2025, and every State fiscal year thereafter, reimbursement rates for licensed or certified substance use disorder treatment providers of ASAM Level 3 residential/inpatient services for persons with substance use disorders shall be adjusted upward by an amount equal to the Consumer Price Index-U from the previous year, not to exceed 2% in any State fiscal year. If there is a decrease in the Consumer Price Index-U, rates shall remain unchanged for that State fiscal year. The Department shall adopt rules, including emergency rules, in accordance with the Illinois Administrative Procedure Act, to implement the provisions of this Section. As used in this Section, "Consumer Price Index-U" means the index published by the Bureau of Labor Statistics of the United States Department of Labor that measures the average change in prices of goods and services purchased by all urban consumers, United States city average, all items, 1982-84 = 100. (b) Parity in community-based behavioral health rates; implementation plan for cost reporting. For the purpose of understanding behavioral health services cost structures and their impact on the Medical Assistance Program, the Department of Healthcare and Family Services shall engage stakeholders to develop a plan for the regular collection of cost reporting for all entity-based substance use disorder providers. Data shall be used to inform on the effectiveness and efficiency of Illinois Medicaid rates. The Department and stakeholders shall develop a plan by April 1, 2024. The Department shall engage stakeholders on implementation of the plan. The plan, at minimum, shall consider all of the following: (1) Alignment with certified community behavioral | ||
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(2) Inclusion of prospective costs to measure what is | ||
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(3) Consideration of differences in collection and | ||
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(4) Consideration of additional administrative time | ||
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(5) Goals, purposes, and usage of data collected from | ||
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(6) Inclusion of qualitative data in addition to | ||
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(7) Technical assistance for providers for completing | ||
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(8) Implementation of a timeline which allows an | ||
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Details from collected cost reports shall be made publicly available on the Department's website and costs shall be used to ensure the effectiveness and efficiency of Illinois Medicaid rates. (c) Reporting; access to substance use disorder treatment services and recovery supports. By no later than April 1, 2024, the Department of Healthcare and Family Services, with input from the Department of Human Services' Division of Substance Use Prevention and Recovery, shall submit a report to the General Assembly regarding access to treatment services and recovery supports for persons diagnosed with a substance use disorder. The report shall include, but is not limited to, the following information: (1) The number of providers enrolled in the Illinois | ||
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(2) The number of Medicaid customers in Illinois with | ||
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(3) A comparison of Illinois' substance use disorder | ||
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(4) Recommendations for and an analysis of the impact | ||
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(5) Recommendations for expanding substance use | ||
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(Source: P.A. 103-102, eff. 6-16-23; 103-588, eff. 6-5-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-48) Sec. 5-48. Increasing behavioral health service capacity in federally qualified health centers. The Department of Healthcare and Family Services shall develop policies and procedures with the goal of increasing the capacity of behavioral health services provided by federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act. Subject to federal approval, the Department shall develop, no later than January 1, 2024, billing policies that provide reimbursement to federally qualified health centers for services rendered by graduate-level, sub-clinical behavioral health professionals who deliver care under the supervision of a fully licensed behavioral health clinician who is licensed as a clinical social worker, clinical professional counselor, marriage and family therapist, or clinical psychologist. To be eligible for reimbursement as provided for in this Section, a graduate-level, sub-clinical professional must meet the educational requirements set forth by the Department of Financial and Professional Regulation for licensed clinical social workers, licensed clinical professional counselors, licensed marriage and family therapists, or licensed clinical psychologists. An individual seeking to fulfill post-degree experience requirements in order to qualify for licensing as a clinical social worker, clinical professional counselor, marriage and family therapist, or clinical psychologist shall also be eligible for reimbursement under this Section so long as the individual is in compliance with all applicable laws and regulations regarding supervision, including, but not limited to, the requirement that the supervised experience be under the order, control, and full professional responsibility of the individual's supervisor or that the individual is designated by a title that clearly indicates training status. The Department shall work with a trade association representing a majority of federally qualified health centers operating in Illinois to develop the policies and procedures required under this Section.(Source: P.A. 103-102, eff. 1-1-24.) |
(305 ILCS 5/5-49) Sec. 5-49. Long-acting reversible contraception. Subject to federal approval, the Department shall adopt policies and rates for long-acting reversible contraception by January 1, 2024 to ensure that reimbursement is not reduced by 4.4% below list price. The Department shall submit any necessary application to the federal Centers for Medicare and Medicaid Services for the purposes of implementing such policies and rates.
(Source: P.A. 103-102, eff. 7-1-23.) |
(305 ILCS 5/5-50) Sec. 5-50. Coverage for mental health and substance use disorder telehealth services. (a) As used in this Section: "Behavioral health care professional" has the meaning given to "health care professional" in Section 5 of the Telehealth Act, but only with respect to professionals licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services engaged in the delivery of mental health or substance use disorder treatment or services. "Behavioral health facility" means a community mental health center, a behavioral health clinic, a substance use disorder treatment program, or a facility or provider licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services. "Behavioral telehealth services" has the meaning given to the term "telehealth services" in Section 5 of the Telehealth Act, but limited solely to mental health and substance use disorder treatment or services to a patient, regardless of patient location. "Distant site" has the meaning given to that term in Section 5 of the Telehealth Act. "Originating site" has the meaning given to that term in Section 5 of the Telehealth Act. (b) The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered. (c) To ensure behavioral telehealth services are equitably provided, coverage required under this Section shall comply with all of the following: (1) The Department and any managed care plans under | ||
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(A) require that in-person contact occur between | ||
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(B) require patients, behavioral health care | ||
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(C) require the use of behavioral telehealth | ||
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(D) require the use of behavioral telehealth | ||
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(E) require a behavioral health care professional | ||
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(F) create geographic or facility restrictions or | ||
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(G) require behavioral health care professionals | ||
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(H) require patients to use behavioral telehealth | ||
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(I) impose upon behavioral telehealth services | ||
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(2) Any cost sharing applicable to services provided | ||
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(3) The Department and any managed care plans under | ||
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(d) For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service. (e) Behavioral health care professionals and behavioral health facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a behavioral telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, 42 CFR Part 2, and the Mental Health and Developmental Disabilities Confidentiality Act. (f) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from providing benefits for other telehealth services. (g) There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate. (h) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from establishing limits on the use of telehealth for a particular behavioral health service when the limits are consistent with generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care. (i) The Department may adopt rules to implement the provisions of this Section.(Source: P.A. 103-243, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-51) Sec. 5-51. Proton beam therapy; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for proton beam therapy. As used in this Section: "Proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells. "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.(Source: P.A. 103-325, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5-52) (Text of Section from P.A. 103-593) Sec. 5-52. Custom prosthetic and orthotic devices; reimbursement rates. Subject to federal approval, for dates of service beginning on and after January 1, 2025, the Department shall increase the current 2024 Medicaid rate by 7% under the medical assistance program for custom prosthetic and orthotic devices. (Source: P.A. 103-593, eff. 6-7-24.) (Text of Section from P.A. 103-703) (This Section may contain text from a Public Act with a delayed effective date) Sec. 5-52. Coverage for hormonal therapy to treat menopause. The medical assistance program shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy.(Source: P.A. 103-703, eff. 1-1-26.) (Text of Section from P.A. 103-914) (This Section may contain text from a Public Act with a delayed effective date) Sec. 5-52. Genetic testing and evidence-based screenings for an inherited gene mutation. (a) In this Section, "genetic testing for an inherited mutation" means germline multi-gene testing for an inherited mutation associated with an increased risk of cancer in accordance with evidence-based, clinical practice guidelines. (b) Subject to federal approval, the medical assistance program, after January 1, 2026, shall provide coverage for clinical genetic testing for an inherited gene mutation for individuals with a personal or family history of cancer, as recommended by a health care professional in accordance with current evidence-based clinical practice guidelines, including, but not limited to, the current version of the National Comprehensive Cancer Network clinical practice guidelines. (c) For individuals with a genetic test that is positive for an inherited mutation associated with an increased risk of cancer, coverage required under this Section shall include any evidence-based screenings, as recommended by a health care professional in accordance with current evidence-based clinical practice guidelines, to the extent that the management recommendation is not already covered by the medical assistance program. In this subsection, "evidence-based cancer screenings" means medically recommended evidence-based screening modalities in accordance with current clinical practice guidelines.(Source: P.A. 103-914, eff. 1-1-25.) |
(305 ILCS 5/5-53) Sec. 5-53. Coverage for self-measure blood pressure monitoring services. Subject to federal approval and notwithstanding any other provision of this Code, for services on and after January 1, 2025, the following self-measure blood pressure monitoring services shall be covered and reimbursed under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article: (1) patient education and training services on the | ||
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(2) separate self-measurement readings and the | ||
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(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-55) Sec. 5-55. Reimbursement for music therapy services. Subject to federal approval, for dates of service beginning on and after July 1, 2025, the Department shall reimburse music therapy services provided by licensed professional music therapists. To be eligible for reimbursement under this Section, music therapy services must be provided by a licensed professional music therapist authorized to practice under the Music Therapy Licensing and Practice Act.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5-60) Sec. 5-60. Optometric services; reimbursement rates. Notwithstanding any other law or rule to the contrary and subject to federal approval, for dates of service beginning on and after January 1, 2025, the reimbursement rates for optometric and optical services for determining refractive state, fitting of spectacles, and fitting of bifocal spectacles shall be increased by 35% above the rates in effect on January 1, 2024.
(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/Art. V-A heading) ARTICLE V-A.
HOSPITAL PROVIDER FUNDING
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(305 ILCS 5/5A-1) (from Ch. 23, par. 5A-1)
Sec. 5A-1. Definitions. As used in this Article, unless the context requires
otherwise:
"Fund" means the Hospital Provider Fund.
"Hospital" means an institution, place, building, or agency located in this
State that is subject to licensure by the Illinois Department of Public Health
under the Hospital Licensing Act, whether public or private and whether
organized for profit or not-for-profit.
"Hospital provider" means a person licensed by the Department of Public
Health to conduct, operate, or maintain a hospital, regardless of whether the
person is a Medicaid provider. For purposes of this paragraph, "person" means
any political subdivision of the State, municipal corporation, individual,
firm, partnership, corporation, company, limited liability company,
association, joint stock association, or trust, or a receiver, executor,
trustee, guardian, or other representative appointed by order of any court.
"Medicare bed days" means, for each hospital, the sum of the number of days that each bed was occupied by a patient who was covered by Title XVIII of the Social Security Act, excluding days attributable to the routine services provided to persons receiving skilled or intermediate long term care services. Medicare bed days shall be computed separately for each hospital operated or maintained by a hospital provider. "Occupied bed days" means the sum of the number of days
that each bed was occupied by a patient for all beds, excluding days attributable to the routine services provided to persons receiving skilled or intermediate long term care services. Occupied bed days shall be computed separately for each
hospital operated or maintained by a hospital provider. "Outpatient gross revenue" means, for each hospital, its total gross charges attributed to outpatient services as reported on the Medicare cost report at Worksheet C, Part I, Column 7, line 101, less the sum of lines 45, 60, 63, 64, 65, 66, 67, and 68 (and any subsets of those lines).
(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12.)
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(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2) (Section scheduled to be repealed on December 31, 2026) Sec. 5A-2. Assessment.
(a)(1)
Subject to Sections 5A-3 and 5A-10, for State fiscal years 2009 through 2018, or as long as continued under Section 5A-16, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $218.38 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days, provided, however, that the amount of $218.38 shall be increased by a uniform percentage to generate an amount equal to 75% of the State share of the payments authorized under Section 5A-12.5, with such increase only taking effect upon the date that a State share for such payments is required under federal law. For the period of April through June 2015, the amount of $218.38 used to calculate the assessment under this paragraph shall, by emergency rule under subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act, be increased by a uniform percentage to generate $20,250,000 in the aggregate for that period from all hospitals subject to the annual assessment under this paragraph. (2) In addition to any other assessments imposed under this Article, effective July 1, 2016 and semi-annually thereafter through June 2018, or as provided in Section 5A-16, in addition to any federally required State share as authorized under paragraph (1), the amount of $218.38 shall be increased by a uniform percentage to generate an amount equal to 75% of the ACA Assessment Adjustment, as defined in subsection (b-6) of this Section. For State fiscal years 2009 through 2018, or as provided in Section 5A-16, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2005 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on December 31, 2006, without regard to any subsequent adjustments or changes to such data. If a hospital's 2005 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State fiscal years 2019 and 2020, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $197.19 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days. For State fiscal years 2019 and 2020, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Notwithstanding any other provision in this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020. (4) Subject to Sections 5A-3 and 5A-10 and to subsection (b-8), for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2026, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $221.50 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days, provided however: for the period of July 1, 2020 through December 31, 2020, (i) the assessment shall be equal to 50% of the annual amount; and (ii) the amount of $221.50 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment, as defined in subsection (b-7). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2026, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Should the change in the assessment methodology for fiscal years 2021 through December 31, 2022 not be approved on or before June 30, 2020, the assessment and payments under this Article in effect for fiscal year 2020 shall remain in place until the new assessment is approved. If the assessment methodology for July 1, 2020 through December 31, 2022, is approved on or after July 1, 2020, it shall be retroactive to July 1, 2020, subject to federal approval and provided that the payments authorized under Section 5A-12.7 have the same effective date as the new assessment methodology. In giving retroactive effect to the assessment approved after June 30, 2020, credit toward the new assessment shall be given for any payments of the previous assessment for periods after June 30, 2020. Notwithstanding any other provision of this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this paragraph until December 31, 2023. Beginning July 1, 2022 and through December 31, 2024, a safety-net hospital that had a change of ownership in calendar year 2021, and whose inpatient utilization had decreased by 90% from the prior year and prior to the change of ownership, may be eligible to pay a tax based on hypothetical data based on a determination of financial distress by the Department. Subject to federal approval, the Department may, by January 1, 2024, develop a hypothetical tax for a specialty cancer hospital which had a structural change of ownership during calendar year 2022 from a for-profit entity to a non-profit entity, and which has experienced a decline of 60% or greater in inpatient days of care as compared to the prior owners 2015 Medicare cost report. This change of ownership may make the hospital eligible for a hypothetical tax under the new hospital provision of the assessment defined in this Section. This new hypothetical tax may be applicable from January 1, 2024 through December 31, 2026. (b) (Blank).
(b-5)(1) Subject to Sections 5A-3 and 5A-10, for the portion of State fiscal year 2012, beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, or as provided in Section 5A-16, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .008766 multiplied by the hospital's outpatient gross revenue, provided, however, that the amount of .008766 shall be increased by a uniform percentage to generate an amount equal to 25% of the State share of the payments authorized under Section 5A-12.5, with such increase only taking effect upon the date that a State share for such payments is required under federal law. For the period beginning June 10, 2012 through June 30, 2012, the annual assessment on outpatient services shall be prorated by multiplying the assessment amount by a fraction, the numerator of which is 21 days and the denominator of which is 365 days. For the period of April through June 2015, the amount of .008766 used to calculate the assessment under this paragraph shall, by emergency rule under subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act, be increased by a uniform percentage to generate $6,750,000 in the aggregate for that period from all hospitals subject to the annual assessment under this paragraph. (2) In addition to any other assessments imposed under this Article, effective July 1, 2016 and semi-annually thereafter through June 2018, in addition to any federally required State share as authorized under paragraph (1), the amount of .008766 shall be increased by a uniform percentage to generate an amount equal to 25% of the ACA Assessment Adjustment, as defined in subsection (b-6) of this Section. For the portion of State fiscal year 2012, beginning June 10, 2012 through June 30, 2012, and State fiscal years 2013 through 2018, or as provided in Section 5A-16, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2009 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on June 30, 2011, without regard to any subsequent adjustments or changes to such data. If a hospital's 2009 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's outpatient gross revenue from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State fiscal years 2019 and 2020, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01358 multiplied by the hospital's outpatient gross revenue. For State fiscal years 2019 and 2020, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's outpatient gross revenue from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. Notwithstanding any other provision in this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020. (4) Subject to Sections 5A-3 and 5A-10 and to subsection (b-8), for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2026, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01525 multiplied by the hospital's outpatient gross revenue, provided however: (i) for the period of July 1, 2020 through December 31, 2020, the assessment shall be equal to 50% of the annual amount; and (ii) the amount of .01525 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment, as defined in subsection (b-7). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2026, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's outpatient revenue data from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Should the change in the assessment methodology above for fiscal years 2021 through calendar year 2022 not be approved prior to July 1, 2020, the assessment and payments under this Article in effect for fiscal year 2020 shall remain in place until the new assessment is approved. If the change in the assessment methodology above for July 1, 2020 through December 31, 2022, is approved after June 30, 2020, it shall have a retroactive effective date of July 1, 2020, subject to federal approval and provided that the payments authorized under Section 12A-7 have the same effective date as the new assessment methodology. In giving retroactive effect to the assessment approved after June 30, 2020, credit toward the new assessment shall be given for any payments of the previous assessment for periods after June 30, 2020. Notwithstanding any other provision of this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this paragraph until December 31, 2023. Beginning July 1, 2022 and through December 31, 2024, a safety-net hospital that had a change of ownership in calendar year 2021, and whose inpatient utilization had decreased by 90% from the prior year and prior to the change of ownership, may be eligible to pay a tax based on hypothetical data based on a determination of financial distress by the Department. (b-6)(1) As used in this Section, "ACA Assessment Adjustment" means: (A) For the period of July 1, 2016 through December | ||
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(B) For the period of January 1, 2017 through June | ||
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(C) For the period of July 1, 2017 through December | ||
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(D) For the period of January 1, 2018 through June | ||
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(i) the amount calculated under this subparagraph | ||
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(ii) the amount calculated under this | ||
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(2) The Department shall complete and apply a final reconciliation of the ACA Assessment Adjustment prior to June 30, 2018 to account for: (A) any differences between the actual payments | ||
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(B) any difference between the estimated | ||
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The Department shall notify hospitals of any additional amounts owed or reduction credits to be applied to the June 2018 ACA Assessment Adjustment. This is to be considered the final reconciliation for the ACA Assessment Adjustment. (3) Notwithstanding any other provision of this Section, if for any reason the scheduled payments under subsection (b) of Section 5A-12.5 are not issued in full by the final day of the period authorized under subsection (b) of Section 5A-12.5, funds collected from each hospital pursuant to subparagraph (D) of paragraph (1) and pursuant to paragraph (2), attributable to the scheduled payments authorized under subsection (b) of Section 5A-12.5 that are not issued in full by the final day of the period attributable to each payment authorized under subsection (b) of Section 5A-12.5, shall be refunded. (4) The increases authorized under paragraph (2) of subsection (a) and paragraph (2) of subsection (b-5) shall be limited to the federally required State share of the total payments authorized under Section 5A-12.5 if the sum of such payments yields an annualized amount equal to or less than $450,000,000, or if the adjustments authorized under subsection (t) of Section 5A-12.2 are found not to be actuarially sound; however, this limitation shall not apply to the fee-for-service payments described in subsection (b) of Section 5A-12.5. (b-7)(1) As used in this Section, "Assessment Adjustment" means: (A) For the period of July 1, 2020 through | ||
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(B) For each calendar quarter beginning January 1, | ||
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(C) Beginning on January 1, 2023, and each subsequent | ||
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(2) The Department shall calculate and notify each hospital of the total Assessment Adjustment and any additional assessment owed by the hospital or refund owed to the hospital on either a semi-annual or annual basis. Such notice shall be issued at least 30 days prior to any period in which the assessment will be adjusted. Any additional assessment owed by the hospital or refund owed to the hospital shall be uniformly applied to the assessment owed by the hospital in monthly installments for the subsequent semi-annual period or calendar year. If no assessment is owed in the subsequent year, any amount owed by the hospital or refund due to the hospital, shall be paid in a lump sum. (3) The Department shall publish all details of the Assessment Adjustment calculation performed each year on its website within 30 days of completing the calculation, and also submit the details of the Assessment Adjustment calculation as part of the Department's annual report to the General Assembly. (b-8) Notwithstanding any other provision of this Article, the Department shall reduce the assessments imposed on each hospital under subsections (a) and (b-5) by the uniform percentage necessary to reduce the total assessment imposed on all hospitals by an aggregate amount of $240,000,000, with such reduction being applied by June 30, 2022. The assessment reduction required for each hospital under this subsection shall be forever waived, forgiven, and released by the Department. (c) (Blank).
(d) Notwithstanding any of the other provisions of this Section, the Department is authorized to adopt rules to reduce the rate of any annual assessment imposed under this Section, as authorized by Section 5-46.2 of the Illinois Administrative Procedure Act.
(e) Notwithstanding any other provision of this Section, any plan providing for an assessment on a hospital provider as a permissible tax under Title XIX of the federal Social Security Act and Medicaid-eligible payments to hospital providers from the revenues derived from that assessment shall be reviewed by the Illinois Department of Healthcare and Family Services, as the Single State Medicaid Agency required by federal law, to determine whether those assessments and hospital provider payments meet federal Medicaid standards. If the Department determines that the elements of the plan may meet federal Medicaid standards and a related State Medicaid Plan Amendment is prepared in a manner and form suitable for submission, that State Plan Amendment shall be submitted in a timely manner for review by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services and subject to approval by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. No such plan shall become effective without approval by the Illinois General Assembly by the enactment into law of related legislation. Notwithstanding any other provision of this Section, the Department is authorized to adopt rules to reduce the rate of any annual assessment imposed under this Section. Any such rules may be adopted by the Department under Section 5-50 of the Illinois Administrative Procedure Act. (Source: P.A. 102-886, eff. 5-17-22; 103-102, eff. 1-1-24.)
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(305 ILCS 5/5A-2.1) Sec. 5A-2.1. Continuation of Section 5A-2 of this Code; validation. (a) The General Assembly finds and declares that: (1) Public Act 101-650, which took effect on July 7, | ||
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(2) The Statute on Statutes sets forth general rules | ||
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(3) This amendatory Act of the 101st General Assembly | ||
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(b) Any construction of this Code that results in the repeal of Section 5A-2 of this Code on July 1, 2020 would be inconsistent with the manifest intent of the General Assembly and repugnant to the context of this Code. (c) It is hereby declared to have been the intent of the General Assembly that Section 5A-2 of this Code shall not be subject to repeal on July 1, 2020. (d) Section 5A-2 of this Code shall be deemed to have been in continuous effect since July 8, 1992 (the effective date of Public Act 87-861), and it shall continue to be in effect, as amended by Public Act 101-650, until it is otherwise lawfully amended or repealed. All previously enacted amendments to the Section taking effect on or after July 8, 1992, are hereby validated. (e) In order to ensure the continuing effectiveness of Section 5A-2 of this Code, that Section is set forth in
full and reenacted by this amendatory Act of the 101st General
Assembly. In this amendatory Act of the 101st General Assembly, the base text of the reenacted Section is set forth as amended by Public Act 101-650. (f) All actions of the Illinois Department or any other person or entity taken in reliance on or pursuant to Section 5A-2 of this Code are hereby validated.
(Source: P.A. 101-655, eff. 3-12-21.) |
(305 ILCS 5/5A-3) (from Ch. 23, par. 5A-3)
Sec. 5A-3. Exemptions.
(a) (Blank).
(b) A hospital provider that is a State agency, a State university, or
a county
with a population of 3,000,000 or more is exempt from the assessment imposed
by Section 5A-2.
(b-2) A hospital provider
that is a county with a population of less than 3,000,000 or a
township,
municipality,
hospital district, or any other local governmental unit is exempt from the
assessment
imposed by Section 5A-2.
(b-5) (Blank).
(b-10) (Blank).
(b-15) (Blank).
(b-20) (Blank).
(b-25) (Blank).
(c) (Blank).
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
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(305 ILCS 5/5A-4) (from Ch. 23, par. 5A-4) Sec. 5A-4. Payment of assessment; penalty.
(a) The assessment imposed by Section 5A-2 for State fiscal year 2009 through State fiscal year 2018 or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the fourteenth State business day of each month.
No installment payment of an assessment imposed by Section 5A-2 shall be due
and
payable, however, until after the Comptroller has issued the payments required under this Article.
Except as provided in subsection (a-5) of this Section, the assessment imposed by subsection (b-5) of Section 5A-2 for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal year 2013 through State fiscal year 2018 or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 17th State business day of each month. No installment payment of an assessment imposed by subsection (b-5) of Section 5A-2 shall be due and payable, however, until after: (i) the Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.4, have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, and the waiver under 42 CFR 433.68 for the assessment imposed by subsection (b-5) of Section 5A-2, if necessary, has been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services; and (ii) the Comptroller has issued the payments required under Section 5A-12.4. Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.4 and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under subsection (b-5) of Section 5A-2 prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller of the payments required under Section 5A-12.4. Except as provided in subsection (a-5) of this Section, the assessment imposed under Section 5A-2 for State fiscal year 2019 and each subsequent State fiscal year shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 17th State business day of each month. The Department has discretion to establish a later date due to delays in payments being made to hospitals as required under Section 5A-12.7. No installment payment of an assessment imposed by Section 5A-2 shall be due and payable, however, until after: (i) the Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.6 or 5A-12.7 have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, and the waiver under 42 CFR 433.68 for the assessment imposed by Section 5A-2, if necessary, has been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services; and (ii) the Comptroller and managed care organizations have issued the payments required under Section 5A-12.6 or 5A-12.7. Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.6 or 5A-12.7 and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under Section 5A-2 prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller and managed care organizations of the payments required under Section 5A-12.6 or 5A-12.7. (a-5) The Illinois Department may accelerate the schedule upon which assessment installments are due and payable by hospitals with a payment ratio greater than or equal to one. Such acceleration of due dates for payment of the assessment may be made only in conjunction with a corresponding acceleration in access payments identified in Section 5A-12.2, Section 5A-12.4, Section 5A-12.6, or Section 5A-12.7 to the same hospitals. For the purposes of this subsection (a-5), a hospital's payment ratio is defined as the quotient obtained by dividing the total payments for the State fiscal year, as authorized under Section 5A-12.2, Section 5A-12.4, Section 5A-12.6, or Section 5A-12.7, by the total assessment for the State fiscal year imposed under Section 5A-2 or subsection (b-5) of Section 5A-2. (b) The Illinois Department is authorized to establish
delayed payment schedules for hospital providers that are unable
to make installment payments when due under this Section due to
financial difficulties, as determined by the Illinois Department.
(c) If a hospital provider fails to pay the full amount of
an installment when due (including any extensions granted under
subsection (b)), there shall, unless waived by the Illinois
Department for reasonable cause, be added to the assessment
imposed by Section 5A-2 a penalty
assessment equal to the lesser of (i) 5% of the amount of the
installment not paid on or before the due date plus 5% of the
portion thereof remaining unpaid on the last day of each 30-day period
thereafter or (ii) 100% of the installment amount not paid on or
before the due date. For purposes of this subsection, payments
will be credited first to unpaid installment amounts (rather than
to penalty or interest), beginning with the most delinquent
installments.
(d) Any assessment amount that is due and payable to the Illinois Department more frequently than once per calendar quarter shall be remitted to the Illinois Department by the hospital provider by means of electronic funds transfer. The Illinois Department may provide for remittance by other means if (i) the amount due is less than $10,000 or (ii) electronic funds transfer is unavailable for this purpose. (Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19; 101-209, eff. 8-5-19; 101-650, eff. 7-7-20.) |
(305 ILCS 5/5A-5) (from Ch. 23, par. 5A-5) Sec. 5A-5. Notice; penalty; maintenance of records.
(a)
The Illinois Department shall send a
notice of assessment to every hospital provider subject
to assessment under this Article. The notice of assessment shall notify the hospital of its assessment and shall be sent after receipt by the Department of notification from the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services that the payment methodologies required under this Article and, if necessary, the waiver granted under 42 CFR 433.68 have been approved. The notice
shall be on a form
prepared by the Illinois Department and shall state the following:
(1) The name of the hospital provider.
(2) The address of the hospital provider's principal | ||
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(3) The occupied bed days, occupied bed days less | ||
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(4) (Blank).
(5) Other reasonable information as determined by the | ||
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(b) If a hospital provider conducts, operates, or
maintains more than one hospital licensed by the Illinois
Department of Public Health, the provider shall pay the
assessment for each hospital separately.
(c) Notwithstanding any other provision in this Article, in
the case of a person who ceases to conduct, operate, or maintain a
hospital in respect of which the person is subject to assessment
under this Article as a hospital provider, the assessment for the State
fiscal year in which the cessation occurs shall be adjusted by
multiplying the assessment computed under Section 5A-2 by a
fraction, the numerator of which is the number of days in the
year during which the provider conducts, operates, or maintains
the hospital and the denominator of which is 365. Immediately
upon ceasing to conduct, operate, or maintain a hospital, the person
shall pay the assessment
for the year as so adjusted (to the extent not previously paid).
(d) Notwithstanding any other provision in this Article, a
provider who commences conducting, operating, or maintaining a
hospital, upon notice by the Illinois Department,
shall pay the assessment computed under Section 5A-2 and
subsection (e) in installments on the due dates stated in the
notice and on the regular installment due dates for the State
fiscal year occurring after the due dates of the initial
notice.
(e)
Notwithstanding any other provision in this Article, for State fiscal years 2009 through 2018, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in 2005, the assessment for that State fiscal year shall be computed on the basis of hypothetical occupied bed days for the full calendar year as determined by the Illinois Department. Notwithstanding any other provision in this Article, for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in 2009, the assessment under subsection (b-5) of Section 5A-2 for that State fiscal year shall be computed on the basis of hypothetical gross outpatient revenue for the full calendar year as determined by the Illinois Department.
Notwithstanding any other provision in this Article, beginning July 1, 2018 through December 31, 2026, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Article, the assessment under paragraph (3) of subsection (a) of Section 5A-2 for the State fiscal year shall be computed on the basis of hypothetical occupied bed days for the full calendar year as determined by the Illinois Department, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020; however, for State fiscal year 2020, the assessment amount shall be increased by the proportion that it represents of the total annual assessment that is generated from all hospitals in order to generate $6,250,000 in the aggregate for that period from all hospitals subject to the annual assessment under this paragraph. Notwithstanding any other provision in this Article, beginning July 1, 2018 through December 31, 2026, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Article, the assessment under subsection (b-5) of Section 5A-2 for that State fiscal year shall be computed on the basis of hypothetical gross outpatient revenue for the full calendar year as determined by the Illinois Department, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020; however, for State fiscal year 2020, the assessment amount shall be increased by the proportion that it represents of the total annual assessment that is generated from all hospitals in order to generate $6,250,000 in the aggregate for that period from all hospitals subject to the annual assessment under this paragraph. (f) Every hospital provider subject to assessment under this Article shall keep sufficient records to permit the determination of adjusted gross hospital revenue for the hospital's fiscal year. All such records shall be kept in the English language and shall, at all times during regular business hours of the day, be subject to inspection by the Illinois Department or its duly authorized agents and employees.
(g) The Illinois Department may, by rule, provide a hospital provider a reasonable opportunity to request a clarification or correction of any clerical or computational errors contained in the calculation of its assessment, but such corrections shall not extend to updating the cost report information used to calculate the assessment.
(h) (Blank).
(Source: P.A. 102-886, eff. 5-17-22.)
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(305 ILCS 5/5A-6) (from Ch. 23, par. 5A-6)
Sec. 5A-6. Disposition of proceeds. The Illinois Department
shall deposit all moneys received from hospital providers under this
Article into the Hospital Provider Fund. Upon certification by
the Illinois Department to the State Comptroller of its intent to
withhold payments from a provider pursuant to Section 5A-7(b), the State
Comptroller shall draw a warrant on the treasury or other fund
held by the State Treasurer, as appropriate. The warrant shall
state the amount for which the provider is entitled to a
warrant, the amount of the deduction, and the reason therefor and
shall direct the State Treasurer to pay the balance to the provider,
all in accordance with Section 10.05 of the State Comptroller Act.
The warrant also shall direct the State Treasurer to transfer the amount of the
deduction so ordered from the treasury or other fund into the
Hospital Provider Fund.
(Source: P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/5A-7) (from Ch. 23, par. 5A-7)
Sec. 5A-7. Administration; enforcement provisions.
(a) The Illinois Department shall establish and maintain a listing of all hospital providers appearing in the licensing records of the Illinois Department of Public Health, which shall show each provider's name and principal place of business and the name and address of each hospital operated, conducted, or maintained by the provider in this State. The Illinois Department shall administer and enforce this Article and collect the assessments and penalty assessments imposed under this Article using procedures employed in its administration of this Code generally. The Illinois Department, its Director, and every hospital provider subject to assessment under this Article shall have the following powers, duties, and rights: (1) The Illinois Department may initiate either | ||
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(2) No proceedings for collection, refund, credit, or | ||
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(3) Any unpaid assessment under this Article shall | ||
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(4) Payments under this Article are not subject to | ||
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(b) In addition to any other remedy provided for and without sending a notice of assessment liability, the Illinois Department may collect an unpaid assessment by withholding, as payment of the assessment, reimbursements or other amounts otherwise payable by the Illinois Department to the hospital provider.
(Source: P.A. 93-659, eff. 2-3-04; 93-841, eff. 7-30-04; 94-242, eff. 7-18-05.)
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(305 ILCS 5/5A-8) (from Ch. 23, par. 5A-8)
Sec. 5A-8. Hospital Provider Fund.
(a) There is created in the State Treasury the Hospital Provider Fund.
Interest earned by the Fund shall be credited to the Fund. The
Fund shall not be used to replace any moneys appropriated to the
Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving moneys
in accordance with Section 5A-6 and disbursing moneys only for the following
purposes, notwithstanding any other provision of law:
(1) For making payments to hospitals as required | ||
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(2) For the reimbursement of moneys collected by the | ||
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(3) For payment of administrative expenses incurred | ||
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(4) For payments of any amounts which are | ||
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(5) For making transfers, as those transfers are | ||
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(6) For making transfers to any other fund in the | ||
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(6.5) For making transfers to the Healthcare Provider | ||
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(7) For making transfers not exceeding the following | ||
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Health and Human Services Medicaid Trust Fund$20,000,000 Long-Term Care Provider Fund$30,000,000 General Revenue Fund$80,000,000. Transfers under this paragraph shall be made within 7 | ||
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(7.1) (Blank).
(7.5) (Blank). (7.8) (Blank). (7.9) (Blank). (7.10) For State fiscal year 2014, for making | ||
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Healthcare Provider Relief Fund$100,000,000 Transfers under this paragraph shall be made within 7 | ||
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The additional amount of transfers in this paragraph | ||
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(7.10a) For State fiscal years 2015 through 2018, for | ||
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Healthcare Provider Relief Fund$50,000,000 Transfers under this paragraph shall be made within 7 | ||
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(7.11) (Blank). (7.12) For State fiscal year 2013, for increasing by | ||
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Healthcare Provider Relief Fund$2,870,000 Since the federal Centers for Medicare and Medicaid | ||
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(7.13) In addition to any other transfers authorized | ||
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(7.14) For making transfers not exceeding the | ||
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Health and Human Services Medicaid Trust Fund$20,000,000 Long-Term Care Provider Fund$30,000,000 Healthcare Provider Relief Fund$325,000,000. Transfers under this paragraph shall be made within 7 | ||
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(7.15) For making transfers not exceeding the | ||
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Health and Human Services Medicaid Trust Fund$20,000,000 Long-Term Care Provider Fund$30,000,000 Healthcare Provider Relief Fund$365,000,000 (7.16) For making transfers not exceeding the | ||
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Health and Human Services Medicaid Trust Fund$10,000,000 Long-Term Care Provider Fund$15,000,000 Healthcare Provider Relief Fund$182,500,000 (8) For making refunds to hospital providers pursuant | ||
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(9) For making payment to capitated managed care | ||
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Disbursements from the Fund, other than transfers authorized under
paragraphs (5) and (6) of this subsection, shall be by
warrants drawn by the State Comptroller upon receipt of vouchers
duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(1) All moneys collected or received by the Illinois | ||
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(2) All federal matching funds received by the | ||
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(3) Any interest or penalty levied in conjunction | ||
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(3.5) As applicable, proceeds from surety bond | ||
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(4) Moneys transferred from another fund in the State | ||
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(5) All other moneys received for the Fund from any | ||
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(d) (Blank).
(Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.)
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(305 ILCS 5/5A-9) (from Ch. 23, par. 5A-9)
Sec. 5A-9. Emergency services audits. The Illinois Department may
audit hospital claims for payment for emergency services provided to a
recipient who does not require admission as an inpatient. The Illinois
Department shall adopt rules that describe how the emergency services audit
process will be conducted. These rules shall include, but need not be
limited to, the following provisions:
(1) The determination that an emergency medical | ||
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(2) The Illinois Department or its authorized | ||
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(3) An emergency services audit shall be limited to a | ||
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(4) Where the purpose of the audit is to determine | ||
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(5) The preliminary audit findings shall be provided | ||
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(6) The Illinois Department or its designated review | ||
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(Source: P.A. 97-48, eff. 6-28-11.)
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(305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)
Sec. 5A-10. Applicability.
(a) The assessment imposed by subsection (a) of Section 5A-2 shall cease to be imposed and the Department's obligation to make payments shall immediately cease, and
any moneys
remaining in the Fund shall be refunded to hospital providers
in proportion to the amounts paid by them, if:
(1) The payments to hospitals required under this | ||
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(2) For State fiscal years 2009 through 2018, and as | ||
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(A) any changes for hospitals described in | ||
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(B) any rates for payments made under this | ||
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(C) any changes proposed in State plan amendment | ||
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(D) in relation to any admissions on or after | ||
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(E) any changes affecting hospitals authorized by | ||
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(F) any changes authorized by Section 14-12 of | ||
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(G) any changes authorized under Section 5-5b.1. (b) The assessment imposed by Section 5A-2 shall not take effect or
shall
cease to be imposed, and the Department's obligation to make payments shall immediately cease, if the assessment is determined to be an impermissible
tax under Title XIX
of the Social Security Act. Moneys in the Hospital Provider Fund derived
from assessments imposed prior thereto shall be
disbursed in accordance with Section 5A-8 to the extent federal financial participation is
not reduced due to the impermissibility of the assessments, and any
remaining
moneys shall be
refunded to hospital providers in proportion to the amounts paid by them.
(c) The assessments imposed by subsection (b-5) of Section 5A-2 shall not take effect or shall cease to be imposed, the Department's obligation to make payments shall immediately cease, and any moneys remaining in the Fund shall be refunded to hospital providers in proportion to the amounts paid by them, if the payments to hospitals required under Section 5A-12.4 or Section 5A-12.6 are not eligible for federal matching funds under Title XIX of the Social Security Act. (d) The assessments imposed by Section 5A-2 shall not take effect or shall cease to be imposed, the Department's obligation to make payments shall immediately cease, and any moneys remaining in the Fund shall be refunded to hospital providers in proportion to the amounts paid by them, if: (1) for State fiscal years 2013 through 2018, and as | ||
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(2) for State fiscal years 2013 through 2018, and as | ||
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(3) for State fiscal years 2015 through 2018, and as | ||
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(e) In State fiscal year 2019 through State fiscal year 2020, the assessments imposed under Section 5A-2 shall not take effect or shall cease to be imposed, the Department's obligation to make payments shall immediately cease, and any moneys remaining in the Fund shall be refunded to hospital providers in proportion to the amounts paid by them, if: (1) the payments to hospitals required under Section | ||
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(2) the Department reduces the overall effective | ||
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(f) Beginning in State Fiscal Year 2021, the assessments imposed under Section 5A-2 shall not take effect or shall cease to be imposed, the Department's obligation to make payments shall immediately cease, and any moneys remaining in the Fund shall be refunded to hospital providers in proportion to the amounts paid by them, if: (1) the payments to hospitals required under Section | ||
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(2) the Department reduces the overall effective rate | ||
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(Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.)
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(305 ILCS 5/5A-11) (from Ch. 23, par. 5A-11)
Sec. 5A-11.
Severability.
If any clause, sentence, Section,
exemption, provision, or part of this Article or the application
thereof to any person or circumstance shall be adjudged to be
unconstitutional or otherwise invalid, the remainder of this
Article or its application to persons or circumstances other than
those to which it is held invalid shall not be affected thereby.
This Article V-A is intended to be separate from and independent
of Articles V-B and V-C, and the application and validity of
this Article V-A shall not be affected by the invalidity of one or
more of Articles V-B and V-C.
(Source: P.A. 87-861.)
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(305 ILCS 5/5A-12)
Sec. 5A-12. (Repealed).
(Source: P.A. 93-1066, eff. 1-15-05. Repealed internally, eff. 7-1-05.) |
(305 ILCS 5/5A-12.1) Sec. 5A-12.1. (Repealed).
(Source: P.A. 94-838, eff. 6-6-06. Repealed internally, eff. 7-1-08.) |
(305 ILCS 5/5A-12.2) (This Section is scheduled to be repealed in accordance with 305 ILCS 5/5A-14) Sec. 5A-12.2. Hospital access payments on or after July 1, 2008. (a) To preserve and improve access to hospital services, for hospital services rendered on or after July 1, 2008, the Illinois Department shall, except for hospitals described in subsection (b) of Section 5A-3, make payments to hospitals as set forth in this Section. These payments shall be paid in 12 equal installments on or before the seventh State business day of each month, except that no payment shall be due within 100 days after the later of the date of notification of federal approval of the payment methodologies required under this Section or any waiver required under 42 CFR 433.68, at which time the sum of amounts required under this Section prior to the date of notification is due and payable. Payments under this Section are not due and payable, however, until (i) the methodologies described in this Section are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed under this Article is determined to be a permissible tax under Title XIX of the Social Security Act. (a-5) The Illinois Department may, when practicable, accelerate the schedule upon which payments authorized under this Section are made. (b) Across-the-board inpatient adjustment. (1) In addition to rates paid for inpatient hospital | ||
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(2) In addition to rates paid for inpatient hospital | ||
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(3) In addition to rates paid for inpatient hospital | ||
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(4) In addition to rates paid for inpatient hospital | ||
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(5) In addition to rates paid for inpatient hospital | ||
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(i) For freestanding children's hospitals as | ||
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(ii) For hospitals other than freestanding | ||
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(c) Outpatient adjustment. (1) In addition to the rates paid for outpatient | ||
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(2) In addition to the rates paid for outpatient | ||
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(d) Medicaid high volume adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay to each Illinois general acute care hospital that provided more than 20,500 Medicaid inpatient days of care in State fiscal year 2005 amounts as follows: (1) For hospitals with a case mix index equal to or | ||
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(2) For hospitals with a case mix index less than the | ||
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(e) Capital adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay an additional payment to each Illinois general acute care hospital that has a Medicaid inpatient utilization rate of at least 10% (as calculated by the Department for the rate year 2007 disproportionate share determination) amounts as follows: (1) For each Illinois general acute care hospital | ||
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(2) For each Illinois general acute care hospital | ||
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(f) Obstetrical care adjustment. (1) In addition to rates paid for inpatient hospital | ||
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(2) In addition to rates paid for inpatient hospital | ||
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(3) In addition to rates paid for inpatient hospital | ||
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(g) Trauma adjustment. (1) In addition to rates paid for inpatient hospital | ||
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(2) In addition to rates paid for inpatient hospital | ||
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(3) In addition to rates paid for inpatient hospital | ||
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(h) Supplemental tertiary care adjustment. In addition to rates paid for inpatient services, the Department shall pay to each Illinois hospital eligible for tertiary care adjustment payments under 89 Ill. Adm. Code 148.296, as in effect for State fiscal year 2007, a supplemental tertiary care adjustment payment equal to the tertiary care adjustment payment required under 89 Ill. Adm. Code 148.296, as in effect for State fiscal year 2007. (i) Crossover adjustment. In addition to rates paid for inpatient services, the Department shall pay each Illinois general acute care hospital that had a ratio of crossover days to total inpatient days for medical assistance programs administered by the Department (utilizing information from 2005 paid claims) greater than 50%, and a case mix index greater than the 65th percentile of case mix indices for all Illinois hospitals, a rate of $1,125 for each Medicaid inpatient day including crossover days. (j) Magnet hospital adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay to each Illinois general acute care hospital and each Illinois freestanding children's hospital that, as of February 1, 2008, was recognized as a Magnet hospital by the American Nurses Credentialing Center and that had a case mix index greater than the 75th percentile of case mix indices for all Illinois hospitals amounts as follows: (1) For hospitals located in a county whose | ||
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(2) For hospitals located in a county whose | ||
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For purposes of this subsection, "eligibility growth factor" means the percentage by which the number of Medicaid recipients in the county increased from State fiscal year 1998 to State fiscal year 2005. (k) For purposes of this Section, a hospital that is enrolled to provide Medicaid services during State fiscal year 2005 shall have its utilization and associated reimbursements annualized prior to the payment calculations being performed under this Section. (l) For purposes of this Section, the terms "Medicaid days", "ambulatory procedure listing services", and "ambulatory procedure listing payments" do not include any days, charges, or services for which Medicare or a managed care organization reimbursed on a capitated basis was liable for payment, except where explicitly stated otherwise in this Section. (m) For purposes of this Section, in determining the percentile ranking of an Illinois hospital's case mix index or capital costs, hospitals described in subsection (b) of Section 5A-3 shall be excluded from the ranking. (n) Definitions. Unless the context requires otherwise or unless provided otherwise in this Section, the terms used in this Section for qualifying criteria and payment calculations shall have the same meanings as those terms have been given in the Illinois Department's administrative rules as in effect on March 1, 2008. Other terms shall be defined by the Illinois Department by rule. As used in this Section, unless the context requires otherwise: "Base inpatient payments" means, for a given hospital, the sum of base payments for inpatient services made on a per diem or per admission (DRG) basis, excluding those portions of per admission payments that are classified as capital payments. Disproportionate share hospital adjustment payments, Medicaid Percentage Adjustments, Medicaid High Volume Adjustments, and outlier payments, as defined by rule by the Department as of January 1, 2008, are not base payments. "Capital costs" means, for a given hospital, the total capital costs determined using the most recent 2005 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on December 31, 2006, divided by the total inpatient days from the same cost report to calculate a capital cost per day. The resulting capital cost per day is inflated to the midpoint of State fiscal year 2009 utilizing the national hospital market price proxies (DRI) hospital cost index. If a hospital's 2005 Medicare cost report is not contained in the Healthcare Cost Report Information System, the Department may obtain the data necessary to compute the hospital's capital costs from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. "Case mix index" means, for a given hospital, the sum of the DRG relative weighting factors in effect on January 1, 2005, for all general acute care admissions for State fiscal year 2005, excluding Medicare crossover admissions and transplant admissions reimbursed under 89 Ill. Adm. Code 148.82, divided by the total number of general acute care admissions for State fiscal year 2005, excluding Medicare crossover admissions and transplant admissions reimbursed under 89 Ill. Adm. Code 148.82. "Medicaid inpatient day" means, for a given hospital, the sum of days of inpatient hospital days provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for admissions occurring during State fiscal year 2005 that was adjudicated by the Department through March 23, 2007. "Medicaid obstetrical day" means, for a given hospital, the sum of days of inpatient hospital days grouped by the Department to DRGs of 370 through 375 provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for admissions occurring during State fiscal year 2005 that was adjudicated by the Department through March 23, 2007. "Outpatient ambulatory procedure listing payments" means, for a given hospital, the sum of payments for ambulatory procedure listing services, as described in 89 Ill. Adm. Code 148.140(b), provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding payments for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for services occurring in State fiscal year 2005 that were adjudicated by the Department through March 23, 2007. (o) The Department may adjust payments made under this Section 5A-12.2 to comply with federal law or regulations regarding hospital-specific payment limitations on government-owned or government-operated hospitals. (p) Notwithstanding any of the other provisions of this Section, the Department is authorized to adopt rules that change the hospital access improvement payments specified in this Section, but only to the extent necessary to conform to any federally approved amendment to the Title XIX State plan. Any such rules shall be adopted by the Department as authorized by Section 5-50 of the Illinois Administrative Procedure Act. Notwithstanding any other provision of law, any changes implemented as a result of this subsection (p) shall be given retroactive effect so that they shall be deemed to have taken effect as of the effective date of this Section. (q) (Blank). (r) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (s) On or after January 1, 2016, and no less than annually thereafter, the Department shall increase capitation payments to capitated managed care organizations (MCOs) to equal the aggregate reduction of payments made in this Section and in Section 5A-12.4 by a uniform percentage on a regional basis to preserve access to hospital services for recipients under the Illinois Medical Assistance Program. The aggregate amount of all increased capitation payments to all MCOs for a fiscal year shall be the amount needed to avoid reduction in payments authorized under Section 5A-15. Payments to MCOs under this Section shall be consistent with actuarial certification and shall be published by the Department each year. Each MCO shall only expend the increased capitation payments it receives under this Section to support the availability of hospital services and to ensure access to hospital services, with such expenditures being made within 15 calendar days from when the MCO receives the increased capitation payment. The Department shall make available, on a monthly basis, a report of the capitation payments that are made to each MCO pursuant to this subsection, including the number of enrollees for which such payment is made, the per enrollee amount of the payment, and any adjustments that have been made. Payments made under this subsection shall be guaranteed by a surety bond obtained by the MCO in an amount established by the Department to approximate one month's liability of payments authorized under this subsection. The Department may advance the payments guaranteed by the surety bond. Payments to MCOs that would be paid consistent with actuarial certification and enrollment in the absence of the increased capitation payments under this Section shall not be reduced as a consequence of payments made under this subsection. As used in this subsection, "MCO" means an entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. (t) On or after July 1, 2014, the Department may increase capitation payments to capitated managed care organizations (MCOs) to equal the aggregate reduction of payments made in Section 5A-12.5 to preserve access to hospital services for recipients under the Illinois Medical Assistance Program. Effective January 1, 2016, the Department shall increase capitation payments to MCOs to include the payments authorized under Section 5A-12.5 to preserve access to hospital services for recipients under the Illinois Medical Assistance Program by ensuring that the reimbursement provided for Affordable Care Act adults enrolled in a MCO is equivalent to the reimbursement provided for Affordable Care Act adults enrolled in a fee-for-service program. Payments to MCOs under this Section shall be consistent with actuarial certification and federal approval (which may be retrospectively determined) and shall be published by the Department each year. Each MCO shall only expend the increased capitation payments it receives under this Section to support the availability of hospital services and to ensure access to hospital services, with such expenditures being made within 15 calendar days from when the MCO receives the increased capitation payment. Payments made under this subsection may be guaranteed by a surety bond obtained by the MCO in an amount established by the Department to approximate one month's liability of payments authorized under this subsection. The Department may advance the payments to hospitals under this subsection, in the event the MCO fails to make such payments. The Department shall make available, on a monthly basis, a report of the capitation payments that are made to each MCO pursuant to this subsection, including the number of enrollees for which such payment is made, the per enrollee amount of the payment, and any adjustments that have been made. Payments to MCOs that would be paid consistent with actuarial certification and enrollment in the absence of the increased capitation payments under this subsection shall not be reduced as a consequence of payments made under this subsection. As used in this subsection, "MCO" means an entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. (Source: P.A. 98-651, eff. 6-16-14; 99-516, eff. 6-30-16.) |
(305 ILCS 5/5A-12.3) Sec. 5A-12.3. (Repealed).
(Source: P.A. 96-821, eff. 11-20-09. Repealed by 305 ILCS 5/5A-14, eff. 7-1-11.) |
(305 ILCS 5/5A-12.4) (This Section is scheduled to be repealed in accordance with 305 ILCS 5/5A-14) Sec. 5A-12.4. Hospital access improvement payments on or after June 10, 2012. (a) Hospital access improvement payments. To preserve and improve access to hospital services, for hospital and physician services rendered on or after June 10, 2012, the Illinois Department shall, except for hospitals described in subsection (b) of Section 5A-3, make payments to hospitals as set forth in this Section. These payments shall be paid in 12 equal installments on or before the 7th State business day of each month, except that no payment shall be due within 100 days after the later of the date of notification of federal approval of the payment methodologies required under this Section or any waiver required under 42 CFR 433.68, at which time the sum of amounts required under this Section prior to the date of notification is due and payable. Payments under this Section are not due and payable, however, until (i) the methodologies described in this Section are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed under subsection (b-5) of Section 5A-2 of this Article is determined to be a permissible tax under Title XIX of the Social Security Act. The Illinois Department shall take all actions necessary to implement the payments under this Section effective June 10, 2012, including but not limited to providing public notice pursuant to federal requirements, the filing of a State Plan amendment, and the adoption of administrative rules. For State fiscal year 2013, payments under this Section shall be increased by 21/365ths. The funding source for these additional payments shall be from the increased assessment under subsection (b-5) of Section 5A-2 that was received from hospital providers under Section 5A-4 for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012. (a-5) Accelerated schedule. The Illinois Department may, when practicable, accelerate the schedule upon which payments authorized under this Section are made. (b) Magnet and perinatal hospital adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay to each Illinois general acute care hospital that, as of August 25, 2011, was recognized as a Magnet hospital by the American Nurses Credentialing Center and that, as of September 14, 2011, was designated as a level III perinatal center amounts as follows: (1) For hospitals with a case mix index equal to or | ||
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(2) For all other hospitals, $170 for each Medicaid | ||
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(c) Trauma level II adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay to each Illinois general acute care hospital that, as of July 1, 2011, was designated as a level II trauma center amounts as follows: (1) For hospitals with a case mix index equal to or | ||
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(2) For all other hospitals, $170 for each Medicaid | ||
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(3) For the purposes of this adjustment, hospitals | ||
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(d) Dual-eligible adjustment. In addition to rates paid for inpatient services, the Department shall pay each Illinois general acute care hospital that had a ratio of crossover days to total inpatient days for programs under Title XIX of the Social Security Act administered by the Department (utilizing information from 2009 paid claims) greater than 50%, and a case mix index equal to or greater than the 75th percentile of case mix indices for all Illinois hospitals, a rate of $400 for each Medicaid inpatient day during State fiscal year 2009 including crossover days. (e) Medicaid volume adjustment. In addition to rates paid for inpatient hospital services, the Department shall pay to each Illinois general acute care hospital that provided more than 10,000 Medicaid inpatient days of care in State fiscal year 2009, has a Medicaid inpatient utilization rate of at least 29.05% as calculated by the Department for the Rate Year 2011 Disproportionate Share determination, and is not eligible for Medicaid Percentage Adjustment payments in rate year 2011 an amount equal to $135 for each Medicaid inpatient day of care provided during State fiscal year 2009. (f) Outpatient service adjustment. In addition to the rates paid for outpatient hospital services, the Department shall pay each Illinois hospital an amount at least equal to $100 multiplied by the hospital's outpatient ambulatory procedure listing services (excluding categories 3B and 3C) and by the hospital's end stage renal disease treatment services provided for State fiscal year 2009. (g) Ambulatory service adjustment. (1) In addition to the rates paid for outpatient | ||
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(2) In addition to the rates paid for outpatient | ||
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(h) Specialty hospital adjustment. In addition to the rates paid for outpatient hospital services, the Department shall pay each Illinois long term acute care hospital and each Illinois hospital devoted exclusively to the treatment of cancer, an amount equal to $700 multiplied by the hospital's outpatient ambulatory procedure listing services and by the hospital's end stage renal disease treatment services (including services provided to individuals eligible for both Medicaid and Medicare) provided for State fiscal year 2009. (h-1) ER Safety Net Payments. In addition to rates paid for outpatient services, the Department shall pay to each Illinois general acute care hospital with an emergency room ratio equal to or greater than 55%, that is not eligible for Medicaid percentage adjustments payments in rate year 2011, with a case mix index equal to or greater than the 20th percentile, and that is not designated as a trauma center by the Illinois Department of Public Health on July 1, 2011, as follows: (1) Each hospital with an emergency room ratio equal | ||
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(2) For all other hospitals, $65 shall be paid for | ||
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(i) Physician supplemental adjustment. In addition to the rates paid for physician services, the Department shall make an adjustment payment for services provided by physicians as follows: (1) Physician services eligible for the adjustment | ||
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(2) The amount of the adjustment for each eligible | ||
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(i-5) For any children's hospital which did not charge for its services during the base period, the Department shall use data supplied by the hospital to determine payments using similar methodologies for freestanding children's hospitals under this Section or Section 5A-12.2. (j) For purposes of this Section, a hospital that is enrolled to provide Medicaid services during State fiscal year 2009 shall have its utilization and associated reimbursements annualized prior to the payment calculations being performed under this Section. (k) For purposes of this Section, the terms "Medicaid days", "ambulatory procedure listing services", and "ambulatory procedure listing payments" do not include any days, charges, or services for which Medicare or a managed care organization reimbursed on a capitated basis was liable for payment, except where explicitly stated otherwise in this Section. (l) Definitions. Unless the context requires otherwise or unless provided otherwise in this Section, the terms used in this Section for qualifying criteria and payment calculations shall have the same meanings as those terms have been given in the Illinois Department's administrative rules as in effect on October 1, 2011. Other terms shall be defined by the Illinois Department by rule. As used in this Section, unless the context requires otherwise: "Case mix index" means, for a given hospital, the sum of
the per admission (DRG) relative weighting factors in effect on January 1, 2005, for all general acute care admissions for State fiscal year 2009, excluding Medicare crossover admissions and transplant admissions reimbursed under 89 Ill. Adm. Code 148.82, divided by the total number of general acute care admissions for State fiscal year 2009, excluding Medicare crossover admissions and transplant admissions reimbursed under 89 Ill. Adm. Code 148.82. "Emergency room ratio" means, for a given hospital, a fraction, the denominator of which is the number of the hospital's outpatient ambulatory procedure listing and end-stage renal disease treatment services provided for State fiscal year 2009 and the numerator of which is the hospital's outpatient ambulatory procedure listing services for categories 3A, 3B, and 3C for State fiscal year 2009. "Medicaid inpatient day" means, for a given hospital, the
sum of days of inpatient hospital days provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for admissions occurring during State fiscal year 2009 that was adjudicated by the Department through June 30, 2010. "Outpatient ambulatory procedure listing services" means, for a given hospital, ambulatory procedure listing services, as described in 89 Ill. Adm. Code 148.140(b), provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding services for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for services occurring in State fiscal year 2009 that were adjudicated by the Department through September 2, 2010. "Outpatient end-stage renal disease treatment services" means, for a given hospital, the services, as described in 89 Ill. Adm. Code 148.140(c), provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding payments for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for services occurring in State fiscal year 2009 that were adjudicated by the Department through September 2, 2010. (m) The Department may adjust payments made under this Section 5A-12.4 to comply with federal law or regulations regarding hospital-specific payment limitations on government-owned or government-operated hospitals. (n) Notwithstanding any of the other provisions of this Section, the Department is authorized to adopt rules that change the hospital access improvement payments specified in this Section, but only to the extent necessary to conform to any federally approved amendment to the Title XIX State plan. Any such rules shall be adopted by the Department as authorized by Section 5-50 of the Illinois Administrative Procedure Act. Notwithstanding any other provision of law, any changes implemented as a result of this subsection (n) shall be given retroactive effect so that they shall be deemed to have taken effect as of the effective date of this Section. (o) The Department of Healthcare and Family Services must submit a State Medicaid Plan Amendment to the Centers for Medicare and Medicaid Services to implement the payments under this Section.
(Source: P.A. 97-688, eff. 6-14-12; 98-104, eff. 7-22-13; 98-463, eff. 8-16-13; 98-756, eff. 7-16-14.) |
(305 ILCS 5/5A-12.5) Sec. 5A-12.5. Affordable Care Act adults; hospital access payments. (a) The Department shall, subject to federal approval, mirror the Medical Assistance hospital reimbursement methodology for Affordable Care Act adults who are enrolled under a fee-for-service or capitated managed care program, including hospital access payments as defined in Section 5A-12.2 of this Article and hospital access improvement payments as defined in Section 5A-12.4 of this Article, in compliance with the equivalent rate provisions of the Affordable Care Act. (b) If the fee-for-service payments authorized under this Section are deemed to be increases to payments for a prior period, the Department shall seek federal approval to issue such increases for the payments made through the period ending on June 30, 2018, or as provided in Section 5A-16, even if such increases are paid out during an extended payment period beyond such date. Payment of such increases beyond such date is subject to federal approval. If the Department receives federal approval of such increases, the Department shall pay such increases on the same schedule as it had used for such payments prior to June 30, 2018. (c) As used in this Section, "Affordable Care Act" is the collective term for the Patient Protection and Affordable Care Act (Pub. L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152).
(Source: P.A. 99-516, eff. 6-30-16; 100-581, eff. 3-12-18.) |
(305 ILCS 5/5A-12.6) Sec. 5A-12.6. (Repealed).
(Source: P.A. 100-581, eff. 3-12-18. Repealed by 305 ILCS 5/5A-14, eff. 7-1-20.) |
(305 ILCS 5/5A-12.7) (Section scheduled to be repealed on December 31, 2026) Sec. 5A-12.7. Continuation of hospital access payments on and after July 1, 2020. (a) To preserve and improve access to hospital services, for hospital services rendered on and after July 1, 2020, the Department shall, except for hospitals described in subsection (b) of Section 5A-3, make payments to hospitals or require capitated managed care organizations to make payments as set forth in this Section. Payments under this Section are not due and payable, however, until: (i) the methodologies described in this Section are approved by the federal government in an appropriate State Plan amendment or directed payment preprint; and (ii) the assessment imposed under this Article is determined to be a permissible tax under Title XIX of the Social Security Act. In determining the hospital access payments authorized under subsection (g) of this Section, if a hospital ceases to qualify for payments from the pool, the payments for all hospitals continuing to qualify for payments from such pool shall be uniformly adjusted to fully expend the aggregate net amount of the pool, with such adjustment being effective on the first day of the second month following the date the hospital ceases to receive payments from such pool. (b) Amounts moved into claims-based rates and distributed in accordance with Section 14-12 shall remain in those claims-based rates. (c) Graduate medical education. (1) The calculation of graduate medical education | ||
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(2) Each hospital's annualized Medicaid Intern | ||
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(3) An annualized Medicaid indirect medical education | ||
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(4) For each hospital, its annualized Medicaid Intern | ||
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(A) For the period of July 1, 2020 through | ||
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(B) For the period of January 1, 2023 through | ||
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(d) Fee-for-service supplemental payments. For the period of July 1, 2020 through December 31, 2022, each Illinois hospital shall receive an annual payment equal to the amounts below, to be paid in 12 equal installments on or before the seventh State business day of each month, except that no payment shall be due within 30 days after the later of the date of notification of federal approval of the payment methodologies required under this Section or any waiver required under 42 CFR 433.68, at which time the sum of amounts required under this Section prior to the date of notification is due and payable. (1) For critical access hospitals, $385 per covered | ||
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(2) For safety-net hospitals, $960 per covered | ||
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(3) For long term acute care hospitals, $295 per | ||
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(4) For freestanding psychiatric hospitals, $125 per | ||
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(5) For freestanding rehabilitation hospitals, $355 | ||
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(6) For all general acute care hospitals and high | ||
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(7) Alzheimer's treatment access payment. Each | ||
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(d-2) Fee-for-service supplemental payments. Beginning January 1, 2023, each Illinois hospital shall receive an annual payment equal to the amounts listed below, to be paid in 12 equal installments on or before the seventh State business day of each month, except that no payment shall be due within 30 days after the later of the date of notification of federal approval of the payment methodologies required under this Section or any waiver required under 42 CFR 433.68, at which time the sum of amounts required under this Section prior to the date of notification is due and payable. The Department may adjust the rates in paragraphs (1) through (7) to comply with the federal upper payment limits, with such adjustments being determined so that the total estimated spending by hospital class, under such adjusted rates, remains substantially similar to the total estimated spending under the original rates set forth in this subsection. (1) For critical access hospitals, as defined in | ||
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(2) For safety-net hospitals, as described in | ||
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(3) For long term acute care hospitals, $550 per | ||
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(4) For freestanding psychiatric hospitals, $200 per | ||
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(5) For freestanding rehabilitation hospitals, $550 | ||
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(6) For all general acute care hospitals and high | ||
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(7) For public hospitals, as defined in subsection | ||
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(8) Alzheimer's treatment access payment. Each | ||
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(e) The Department shall require managed care organizations (MCOs) to make directed payments and pass-through payments according to this Section. Each calendar year, the Department shall require MCOs to pay the maximum amount out of these funds as allowed as pass-through payments under federal regulations. The Department shall require MCOs to make such pass-through payments as specified in this Section. The Department shall require the MCOs to pay the remaining amounts as directed Payments as specified in this Section. The Department shall issue payments to the Comptroller by the seventh business day of each month for all MCOs that are sufficient for MCOs to make the directed payments and pass-through payments according to this Section. The Department shall require the MCOs to make pass-through payments and directed payments using electronic funds transfers (EFT), if the hospital provides the information necessary to process such EFTs, in accordance with directions provided monthly by the Department, within 7 business days of the date the funds are paid to the MCOs, as indicated by the "Paid Date" on the website of the Office of the Comptroller if the funds are paid by EFT and the MCOs have received directed payment instructions. If funds are not paid through the Comptroller by EFT, payment must be made within 7 business days of the date actually received by the MCO. The MCO will be considered to have paid the pass-through payments when the payment remittance number is generated or the date the MCO sends the check to the hospital, if EFT information is not supplied. If an MCO is late in paying a pass-through payment or directed payment as required under this Section (including any extensions granted by the Department), it shall pay a penalty, unless waived by the Department for reasonable cause, to the Department equal to 5% of the amount of the pass-through payment or directed payment not paid on or before the due date plus 5% of the portion thereof remaining unpaid on the last day of each 30-day period thereafter. Payments to MCOs that would be paid consistent with actuarial certification and enrollment in the absence of the increased capitation payments under this Section shall not be reduced as a consequence of payments made under this subsection. The Department shall publish and maintain on its website for a period of no less than 8 calendar quarters, the quarterly calculation of directed payments and pass-through payments owed to each hospital from each MCO. All calculations and reports shall be posted no later than the first day of the quarter for which the payments are to be issued. (f)(1) For purposes of allocating the funds included in capitation payments to MCOs, Illinois hospitals shall be divided into the following classes as defined in administrative rules: (A) Beginning July 1, 2020 through December 31, 2022, | ||
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(B) Safety-net hospitals, except that stand-alone | ||
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(C) Long term acute care hospitals. (D) Freestanding psychiatric hospitals. (E) Freestanding rehabilitation hospitals. (F) Beginning January 1, 2023, "public hospital" | ||
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(G) High Medicaid hospitals. (i) As used in this Section, "high Medicaid | ||
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(I) For the payout periods July 1, 2020 | ||
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(II) For the calendar year beginning January | ||
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(ii) For the calendar year beginning January 1, | ||
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(H) General acute care hospitals. As used under this | ||
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(2) Hospitals' qualification for each class shall be assessed prior to the beginning of each calendar year and the new class designation shall be effective January 1 of the next year. The Department shall publish by rule the process for establishing class determination. (3) Beginning January 1, 2024, the Department may reassign hospitals or entire hospital classes as defined above, if federal limits on the payments to the class to which the hospitals are assigned based on the criteria in this subsection prevent the Department from making payments to the class that would otherwise be due under this Section. The Department shall publish the criteria and composition of each new class based on the reassignments, and the projected impact on payments to each hospital under the new classes on its website by November 15 of the year before the year in which the class changes become effective. (g) Fixed pool directed payments. Beginning July 1, 2020, the Department shall issue payments to MCOs which shall be used to issue directed payments to qualified Illinois safety-net hospitals and critical access hospitals on a monthly basis in accordance with this subsection. Prior to the beginning of each Payout Quarter beginning July 1, 2020, the Department shall use encounter claims data from the Determination Quarter, accepted by the Department's Medicaid Management Information System for inpatient and outpatient services rendered by safety-net hospitals and critical access hospitals to determine a quarterly uniform per unit add-on for each hospital class. (1) Inpatient per unit add-on. A quarterly uniform | ||
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(A) Each hospital in the class shall have a | ||
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(B) Each hospital shall be paid 1/3 of its | ||
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(2) Outpatient per unit add-on. A quarterly uniform | ||
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(A) Each hospital in the class shall have a | ||
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(B) Each hospital shall be paid 1/3 of its | ||
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(3) Each MCO shall pay each hospital the Monthly | ||
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(4) Definitions. As used in this subsection: (A) "Payout Quarter" means each 3 month calendar | ||
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(B) "Determination Quarter" means each 3 month | ||
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(5) For the period July 1, 2020 through December | ||
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(A) $2,894,500 for hospital inpatient services | ||
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(B) $4,294,374 for hospital outpatient services | ||
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(C) $29,109,330 for hospital inpatient services | ||
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(D) $35,041,218 for hospital outpatient services | ||
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(6) For the period January 1, 2023 through December | ||
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(A) Hospital inpatient services for critical | ||
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(B) Hospital outpatient services for critical | ||
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(C) Hospital inpatient services for public | ||
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(D) Hospital outpatient services for public | ||
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(E) Hospital inpatient services for safety-net | ||
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(F) Hospital outpatient services for safety-net | ||
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(7) Semi-annual rate maintenance review. The | ||
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(A) The Department shall calculate the effective | ||
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(B) If the effective rate calculated in | ||
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(h) Fixed rate directed payments. Effective July 1, 2020, the Department shall issue payments to MCOs which shall be used to issue directed payments to Illinois hospitals not identified in paragraph (g) on a monthly basis. Prior to the beginning of each Payout Quarter beginning July 1, 2020, the Department shall use encounter claims data from the Determination Quarter, accepted by the Department's Medicaid Management Information System for inpatient and outpatient services rendered by hospitals in each hospital class identified in paragraph (f) and not identified in paragraph (g). For the period July 1, 2020 through December 2020, the Department shall direct MCOs to make payments as follows: (1) For general acute care hospitals an amount equal | ||
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(2) For general acute care hospitals an amount equal | ||
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(3) For general acute care hospitals an amount equal | ||
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(4) For general acute care hospitals an amount equal | ||
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(5) For general acute care hospitals an amount equal | ||
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(6) For general acute care hospitals an amount equal | ||
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(7) For high Medicaid hospitals an amount equal to | ||
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(8) For high Medicaid hospitals an amount equal to | ||
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(9) For high Medicaid hospitals an amount equal to | ||
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(10) For high Medicaid hospitals an amount equal to | ||
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(11) For high Medicaid hospitals an amount equal to | ||
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(12) For high Medicaid hospitals an amount equal to | ||
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(13) For long term acute care hospitals the amount of | ||
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(14) For psychiatric hospitals the amount of $210 | ||
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(15) For psychiatric hospitals the amount of $250 | ||
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(16) For rehabilitation hospitals the amount of $410 | ||
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(17) For rehabilitation hospitals the amount of $100 | ||
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(18) Effective for the Payout Quarter beginning | ||
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(19) Each hospital shall be paid 1/3 of their | ||
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(20) Each MCO shall pay each hospital the Monthly | ||
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Notwithstanding any other provision of this subsection, if the Department determines that the actual total hospital utilization data that is used to calculate the fixed rate directed payments is substantially different than anticipated when the rates in this subsection were initially determined for unforeseeable circumstances (such as the COVID-19 pandemic or some other public health emergency), the Department may adjust the rates specified in this subsection so that the total directed payments approximate the total spending amount anticipated when the rates were initially established. Definitions. As used in this subsection: (A) "Payout Quarter" means each calendar quarter, | ||
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(B) "Determination Quarter" means each calendar | ||
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(C) "Case mix index" means a hospital specific | ||
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(i) Beginning January 1, 2021, the rates for directed payments shall be recalculated in order to spend the additional funds for directed payments that result from reduction in the amount of pass-through payments allowed under federal regulations. The additional funds for directed payments shall be allocated proportionally to each class of hospitals based on that class' proportion of services. (1) Beginning January 1, 2024, the fixed pool | ||
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(2) Beginning January 1, 2024, the fixed rates for | ||
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(j) Pass-through payments. (1) For the period July 1, 2020 through December 31, | ||
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(A) $390,487,095 to safety-net hospitals. (B) $62,553,886 to critical access hospitals. (C) $345,021,438 to high Medicaid hospitals. (D) $551,429,071 to general acute care hospitals. (E) $27,283,870 to long term acute care hospitals. (F) $40,825,444 to freestanding psychiatric | ||
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(G) $9,652,108 to freestanding rehabilitation | ||
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(2) For the period of July 1, 2020 through December | ||
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(3) For the calendar year beginning January 1, 2023, | ||
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(4) For the calendar years beginning January 1, 2021 | ||
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(k) At least 30 days prior to each calendar year, the Department shall notify each hospital of changes to the payment methodologies in this Section, including, but not limited to, changes in the fixed rate directed payment rates, the aggregate pass-through payment amount for all hospitals, and the hospital's pass-through payment amount for the upcoming calendar year. (l) Notwithstanding any other provisions of this Section, the Department may adopt rules to change the methodology for directed and pass-through payments as set forth in this Section, but only to the extent necessary to obtain federal approval of a necessary State Plan amendment or Directed Payment Preprint or to otherwise conform to federal law or federal regulation. (m) As used in this subsection, "managed care organization" or "MCO" means an entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis, excluding contracted entities for dual eligible or Department of Children and Family Services youth populations. (n) In order to address the escalating infant mortality rates among minority communities in Illinois, the State shall, subject to appropriation, create a pool of funding of at least $50,000,000 annually to be disbursed among safety-net hospitals that maintain perinatal designation from the Department of Public Health. The funding shall be used to preserve or enhance OB/GYN services or other specialty services at the receiving hospital, with the distribution of funding to be established by rule and with consideration to perinatal hospitals with safe birthing levels and quality metrics for healthy mothers and babies. (o) In order to address the growing challenges of providing stable access to healthcare in rural Illinois, including perinatal services, behavioral healthcare including substance use disorder services (SUDs) and other specialty services, and to expand access to telehealth services among rural communities in Illinois, the Department of Healthcare and Family Services shall administer a program to provide at least $10,000,000 in financial support annually to critical access hospitals for delivery of perinatal and OB/GYN services, behavioral healthcare including SUDS, other specialty services and telehealth services. The funding shall be used to preserve or enhance perinatal and OB/GYN services, behavioral healthcare including SUDS, other specialty services, as well as the explanation of telehealth services by the receiving hospital, with the distribution of funding to be established by rule. (p) For calendar year 2023, the final amounts, rates, and payments under subsections (c), (d-2), (g), (h), and (j) shall be established by the Department, so that the sum of the total estimated annual payments under subsections (c), (d-2), (g), (h), and (j) for each hospital class for calendar year 2023, is no less than: (1) $858,260,000 to safety-net hospitals. (2) $86,200,000 to critical access hospitals. (3) $1,765,000,000 to high Medicaid hospitals. (4) $673,860,000 to general acute care hospitals. (5) $48,330,000 to long term acute care hospitals. (6) $89,110,000 to freestanding psychiatric hospitals. (7) $24,300,000 to freestanding rehabilitation | ||
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(8) $32,570,000 to public hospitals. (q) Hospital Pandemic Recovery Stabilization Payments. The Department shall disburse a pool of $460,000,000 in stability payments to hospitals prior to April 1, 2023. The allocation of the pool shall be based on the hospital directed payment classes and directed payments issued, during Calendar Year 2022 with added consideration to safety net hospitals, as defined in subdivision (f)(1)(B) of this Section, and critical access hospitals. (Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff. 6-16-23; 103-593, eff. 6-7-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/5A-12.8) Sec. 5A-12.8. Report to the General Assembly. In order to facilitate transparency, accountability, and future policy development by the General Assembly, the Department shall provide the reports and information specified in this Section.
By February 1, 2022, the Department shall provide a report to the General Assembly that includes, but is not limited to, the following: (1) information on the total payments made under | ||
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(2) after consulting the hospital community and other | ||
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(A) policies and practices to improve access to | ||
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(B) analysis of charity care by hospital; (C) revisions to the payment methodology for | ||
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(D) revisions to the directed payment | ||
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(E) the definitions of and criteria to qualify as | ||
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(F) options to revise the methodology for | ||
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(Source: P.A. 101-650, eff. 7-7-20.) |
(305 ILCS 5/5A-13)
Sec. 5A-13. Emergency rulemaking. (a) The Department of Healthcare and Family Services (formerly Department of
Public Aid) may adopt rules necessary to implement
this amendatory Act of the 94th General Assembly
through the use of emergency rulemaking in accordance with
Section 5-45 of the Illinois Administrative Procedure Act.
For purposes of that Act, the General Assembly finds that the
adoption of rules to implement this
amendatory Act of the 94th General Assembly is deemed an
emergency and necessary for the public interest, safety, and welfare.
(b) The Department of Healthcare and Family Services may adopt rules necessary to implement
this amendatory Act of the 97th General Assembly
through the use of emergency rulemaking in accordance with
Section 5-45 of the Illinois Administrative Procedure Act.
For purposes of that Act, the General Assembly finds that the
adoption of rules to implement this
amendatory Act of the 97th General Assembly is deemed an
emergency and necessary for the public interest, safety, and welfare. (c) The Department of Healthcare and Family Services may adopt rules necessary to initially implement the changes to Articles 5, 5A, 12, and 14 of this Code under this amendatory Act of the 100th General Assembly through the use of emergency rulemaking in accordance with subsection (aa) of Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the General Assembly finds that the adoption of rules to implement the changes to Articles 5, 5A, 12, and 14 of this Code under this amendatory Act of the 100th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare. The 24-month limitation on the adoption of emergency rules does not apply to rules adopted to initially implement the changes to Articles 5, 5A, 12, and 14 of this Code under this amendatory Act of the 100th General Assembly. For purposes of this subsection, "initially" means any emergency rules necessary to immediately implement the changes authorized to Articles 5, 5A, 12, and 14 of this Code under this amendatory Act of the 100th General Assembly; however, emergency rulemaking authority shall not be used to make changes that could otherwise be made following the process established in the Illinois Administrative Procedure Act. (d) The Department of Healthcare and Family Services may on a one-time-only basis adopt rules necessary to initially implement the changes to Articles 5A and 14 of this Code under this amendatory Act of the 100th General Assembly through the use of emergency rulemaking in accordance with subsection (ee) of Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the General Assembly finds that the adoption of rules on a one-time-only basis to implement the changes to Articles 5A and 14 of this Code under this amendatory Act of the 100th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare. The 24-month limitation on the adoption of emergency rules does not apply to rules adopted to initially implement the changes to Articles 5A and 14 of this Code under this amendatory Act of the 100th General Assembly. (e) The Department of Healthcare and Family Services may adopt rules necessary to implement
the changes made to Articles 5, 5A, 12, and 14 of this Code by this amendatory Act of the 101st General Assembly through the use of emergency rulemaking in accordance with
Section 5-45.1 of the Illinois Administrative Procedure Act. The 24-month limitation on the adoption of emergency rules does not apply to rules adopted under this Section. The General Assembly finds that the adoption of rules to implement the changes made to Articles 5, 5A, 12, and 14 of this Code by this amendatory Act of the 101st General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare. (Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19; 101-650, eff. 7-7-20.) |
(305 ILCS 5/5A-14) Sec. 5A-14. Repeal of assessments and disbursements. (a) Section 5A-2 is repealed on December 31, 2026. (b) Section 5A-12 is repealed on July 1, 2005.
(c) Section 5A-12.1 is repealed on July 1, 2008.
(d) Section 5A-12.2 and Section 5A-12.4 are repealed on July 1, 2018, subject to Section 5A-16. (e) Section 5A-12.3 is repealed on July 1, 2011. (f) Section 5A-12.6 is repealed on July 1, 2020. (g) Section 5A-12.7 is repealed on December 31, 2026. (Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.) |
(305 ILCS 5/5A-15) Sec. 5A-15. Protection of federal revenue. (a) If the federal Centers for Medicare and Medicaid Services finds that any federal upper payment limit applicable to the payments under this Article is exceeded then: (1) (i) if such finding is made before payments have | ||
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(2) any assessment rate imposed under this Article | ||
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(3) any transfers from the Hospital Provider Fund | ||
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(b) Any payment reductions made under the authority granted in this Section are exempt from the requirements and actions under Section 5A-10.
(c) If any payments made as a result of the requirements of this Article are subject to a disallowance, deferral, or adjustment of federal matching funds then: (1) the Department shall recoup the payments related | ||
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(2) if the payments that are subject to a | ||
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(3) any assessment paid to the Department by | ||
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If an MCO is unable to recoup funds from a hospital for any reason, then the Department, upon written notice from an MCO, shall work in good faith with the MCO to mitigate losses associated with the lack of recoupment. Losses by an MCO shall not exceed 1% of the total payments distributed by the MCO to hospitals pursuant to the Hospital Assessment Program. (Source: P.A. 100-580, eff. 3-12-18; 100-581, eff. 3-12-18; 101-81, eff. 7-12-19.) |
(305 ILCS 5/5A-16) Sec. 5A-16. State fiscal year 2019 implementation protection. (a) To preserve access to hospital services and to ensure continuity of payments and stability of access to hospital services, it is the intent of the General Assembly that there not be a gap in payments to hospitals while the changes authorized under Public Act 100-581 are being reviewed by the federal Centers for Medicare and Medicaid Services and implemented by the Department. Therefore, pending the review and approval of the changes to the assessment and hospital reimbursement methodologies authorized under Public Act 100-581 by the federal Centers for Medicare and Medicaid Services and the final implementation of such program by the Department, the Department shall take all actions necessary to continue the reimbursement methodologies and payments to hospitals that are changed under Public Act 100-581, as they are in effect on June 30, 2018, until the first day of the second month after the new and revised methodologies and payments authorized under Public Act 100-581 are effective and implemented by the Department. Such actions by the Department shall include, but not be limited to, requesting prior to June 15, 2018 the extension of any federal approval of the currently approved payment methodologies contained in Illinois' Medicaid State Plan while the federal Centers for Medicare and Medicaid Services reviews the proposed changes authorized under Public Act 100-581. (b) Notwithstanding any other provision of this Code, if the federal Centers for Medicare and Medicaid Services should approve the continuation of the reimbursement methodologies and payments to hospitals under Sections 5A-12.5 and 14-12, as they are in effect on June 30, 2018, until the new and revised methodologies and payments authorized under Sections 5A-12.6 and 14-12 of this Code are federally approved, then the reimbursement methodologies and payments to hospitals under Sections 5A-12.2, 5A-12.4, 5A-12.5, and 14-12, and the assessments imposed under Section 5A-2, as they are in effect on June 30, 2018, shall continue until the effective date of the new and revised methodologies and payments, which shall be the first day of the second month following the date of approval by the federal Centers for Medicare and Medicaid Services.
(c) Notwithstanding any other provision of this Code, if by July 11, 2018 the federal Centers for Medicare and Medicaid Services has neither approved the changes authorized under Public Act 100-581 nor has formally approved an extension of the reimbursement methodologies and payments to hospitals under Sections 5A-12.5 and 14-12 as they are in effect on June 30, 2018, then the following shall apply: (1) All reimbursement methodologies and payments for | ||
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(2) All supplemental payments to hospitals | ||
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(3) All assessments imposed under Section 5A-2, as | ||
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(4) Notwithstanding any other provision in this | ||
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Notwithstanding any other provision in this | ||
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Advance payments under this paragraph (4) shall be | ||
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As used in this paragraph (4), "safety-net hospital" | ||
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As used in this paragraph (4), "critical access | ||
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(5) The changes authorized under this subsection (c) | ||
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(Source: P.A. 100-581, eff. 3-12-18; 100-646, eff. 7-27-18.) |
(305 ILCS 5/5A-17) Sec. 5A-17. Recovery of payments; liens. (a) As a condition of receiving payments pursuant to subsections (d) and (k) of Section 5A-12.7 for State Fiscal Year 2021, a for-profit general acute care hospital that ceases to provide hospital services before July 1, 2021 and within 12 months of a change in the hospital's ownership status from not-for-profit to investor owned, shall be obligated to pay to the Department an amount equal to the payments received pursuant to subsections (d) and (k) of Section 5A-12.7 since the change in ownership status to the cessation of hospital services. The obligated amount shall be due immediately and must be paid to the Department within 10 days of ceasing to provide services or pursuant to a payment plan approved by the Department unless the hospital requests a hearing under paragraph (d) of this Section. The obligation under this Section shall not apply to a hospital that ceases to provide services under circumstances that include: implementation of a transformation project approved by the Department under subsection (d-5) of Section 14-12; emergencies as declared by federal, State, or local government; actions approved or required by federal, State, or local government; actions taken in compliance with the Illinois Health Facilities Planning Act; or other circumstances beyond the control of the hospital provider or for the benefit of the community previously served by the hospital, as determined on a case-by-case basis by the Department. (a-5) For State Fiscal Year 2022, a general acute care hospital that ceases to provide hospital services before July 1, 2022 and within 12 months of a change in the hospital's ownership status that was approved by the Health Facilities Services Review Board between March 1, 2021 and March 31, 2021, shall be obligated to pay to the Department an amount equal to the payments received in State Fiscal Year 2022 pursuant to subsections (d) and (k) of Section 5A-12.7 since the change in ownership status to the cessation of hospital services. The obligated amount shall be due immediately and must be paid to the Department within 30 days of ceasing to provide services or pursuant to a payment plan approved by the Department unless the hospital requests a proceeding under paragraph (b) of this Section. The obligation under this Section shall not apply to a hospital that ceases to provide services under circumstances that include: implementation of a transformation project approved by the Department under subsection (d-5) of Section 14-12; emergencies as declared by federal, State, or local government; actions approved or required by federal, State, or local government; actions taken in compliance with the Illinois Health Facilities Planning Act; or other circumstances beyond the control of the hospital provider or for the benefit of the community previously served by the hospital, as determined on a case-by-case basis by the Department. (b) The Illinois Department shall administer and enforce this Section and collect the obligations imposed under this Section using procedures employed in its administration of this Code generally. The Illinois Department, its Director, and every hospital provider subject to this Section shall have the following powers, duties, and rights: (1) The Illinois Department may initiate either | ||
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(2) No proceedings for collection, refund, credit, or | ||
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(3) Any unpaid obligation under this Section shall | ||
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(c) In addition to any other remedy provided for, the Illinois Department may collect an unpaid obligation by withholding, as payment of the amount due, reimbursements or other amounts otherwise payable by the Illinois Department to the hospital provider.
(Source: P.A. 101-650, eff. 7-7-20; 102-16, eff. 6-17-21.) |
(305 ILCS 5/Art. V-B heading) ARTICLE V-B.
LONG-TERM CARE PROVIDER FUNDING
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(305 ILCS 5/5B-1) (from Ch. 23, par. 5B-1)
Sec. 5B-1. Definitions. As used in this Article, unless the
context requires otherwise:
"Fund" means the Long-Term Care Provider Fund.
"Long-term care facility" means (i) a nursing facility, whether
public or private and whether organized for profit or
not-for-profit, that is subject to licensure by the Illinois Department
of Public Health under the Nursing Home Care Act, the ID/DD Community Care Act, or the MC/DD Act, including a
county nursing home directed and maintained under Section
5-1005 of the Counties Code, and (ii) a part of a hospital in
which skilled or intermediate long-term care services within the
meaning of Title XVIII or XIX of the Social Security Act are
provided; except that the term "long-term care facility" does
not include a facility operated by a State agency or operated solely as an intermediate care
facility for the mentally retarded within the meaning of Title
XIX of the Social Security Act.
"Long-term care provider" means (i) a person licensed
by the Department of Public Health to operate and maintain a
skilled nursing or intermediate long-term care facility or (ii) a hospital provider that
provides skilled or intermediate long-term care services within
the meaning of Title XVIII or XIX of the Social Security Act.
For purposes of this paragraph, "person" means any political
subdivision of the State, municipal corporation, individual,
firm, partnership, corporation, company, limited liability
company, association, joint stock association, or trust, or a
receiver, executor, trustee, guardian, or other representative
appointed by order of any court. "Hospital provider" means a
person licensed by the Department of Public Health to conduct,
operate, or maintain a hospital.
"Occupied bed days" shall be computed separately for
each long-term care facility operated or maintained by a long-term
care provider, and means the sum for all beds of the number
of days during the month on which each bed was occupied by a
resident, other than a resident for whom Medicare Part A is the primary payer. For a resident whose care is covered by the Medicare Medicaid Alignment initiative demonstration, Medicare Part A is considered the primary payer.
(Source: P.A. 98-651, eff. 6-16-14; 99-180, eff. 7-29-15.)
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(305 ILCS 5/5B-2) (from Ch. 23, par. 5B-2)
Sec. 5B-2. Assessment; no local authorization to tax.
(a) For the privilege of engaging in the occupation of long-term care
provider, beginning July 1, 2011 through June 30, 2022, or upon federal approval by the Centers for Medicare and Medicaid Services of the long-term care provider assessment described in subsection (a-1), whichever is later, an assessment is imposed upon each long-term care provider in an amount equal to $6.07 times the number of occupied bed days due and payable each month. Notwithstanding any provision of any other Act to the
contrary, this assessment shall be construed as a tax, but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.
(a-1) For the privilege of engaging in the occupation of long-term care provider for each occupied non-Medicare bed day, beginning July 1, 2022, an assessment is imposed upon each long-term care provider in an amount varying with the number of paid Medicaid resident days per annum in the facility with the following schedule of occupied bed tax amounts. This assessment is due and payable each month. The tax shall follow the schedule below and be rebased by the Department on an annual basis. The Department shall publish each facility's rebased tax rate according to the schedule in this Section 30 days prior to the beginning of the 6-month period beginning July 1, 2022 and thereafter 30 days prior to the beginning of each calendar year which shall incorporate the number of paid Medicaid days used to determine each facility's rebased tax rate. (1) 0-5,000 paid Medicaid resident days per annum, | ||
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(2) 5,001-15,000 paid Medicaid resident days per | ||
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(3) 15,001-35,000 paid Medicaid resident days per | ||
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(4) 35,001-55,000 paid Medicaid resident days per | ||
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(5) 55,001-65,000 paid Medicaid resident days per | ||
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(6) 65,001+ paid Medicaid resident days per annum, | ||
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(7) Any non-profit nursing facilities without | ||
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Notwithstanding any provision of any other Act to the contrary, this assessment shall be construed as a tax but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider. For each new calendar year and for the 6-month period beginning July 1, 2022, a facility's paid Medicaid resident days per annum shall be determined using the Department's Medicaid Management Information System to include Medicaid resident days for the year ending 9 months earlier. (b) Nothing in this amendatory Act of 1992 shall be construed to
authorize any home rule unit or other unit of local government to license
for revenue or impose a tax or assessment upon long-term care providers or
the occupation of long-term care provider, or a tax or assessment measured
by the income or earnings or occupied bed days of a long-term care provider.
(c) The assessment imposed by this Section shall not be due and payable, however, until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under Section 5-5.2 of this Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and that the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. (Source: P.A. 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23.)
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(305 ILCS 5/5B-3) (from Ch. 23, par. 5B-3)
Sec. 5B-3.
Exemptions.
A long-term care provider which is a
county with a population of more than 3 million that makes
intergovernmental transfer payments as provided in Section 15-3 of
this Code shall be exempt from the assessment imposed by Section
5B-2 unless the exemption is adjudged to
be unconstitutional or otherwise invalid, in which case the
county shall pay the assessment imposed by Section 5B-2 for all
assessment periods beginning on or after July 1, 1992,
and the assessment so paid shall be creditable against the
intergovernmental transfer payments.
(Source: P.A. 87-861.)
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(305 ILCS 5/5B-4) (from Ch. 23, par. 5B-4)
Sec. 5B-4. Payment of assessment; penalty.
(a) The assessment imposed by Section 5B-2 shall be due and payable monthly, on the last State business day of the month for occupied bed days reported for the preceding third month prior to the month in which the tax is payable and due. A facility that has delayed payment due to the State's failure to reimburse for services rendered may request an extension on the due date for payment pursuant to subsection (b) and shall pay the assessment within 30 days of reimbursement by the Department.
The Illinois Department may provide that county nursing homes directed and
maintained pursuant to Section 5-1005 of the Counties Code may meet their
assessment obligation by certifying to the Illinois Department that county
expenditures have been obligated for the operation of the county nursing
home in an amount at least equal to the amount of the assessment.
(a-5) The Illinois Department shall provide for an electronic submission process for each long-term care facility to report at a minimum the number of occupied bed days of the long-term care facility for the reporting period and other reasonable information the Illinois Department requires for the administration of its responsibilities under this Code. Beginning July 1, 2013, a separate electronic submission shall be completed for each long-term care facility in this State operated by a long-term care provider. The Illinois Department shall provide a self-reporting notice of the assessment form that the long-term care facility completes for the required period and submits with its assessment payment to the Illinois Department. To the extent practicable, the Department shall coordinate the assessment reporting requirements with other reporting required of long-term care facilities. (b) The Illinois Department is authorized to establish
delayed payment schedules for long-term care providers that are
unable to make assessment payments when due under this Section
due to financial difficulties, as determined by the Illinois
Department. The Illinois Department may not deny a request for delay of payment of the assessment imposed under this Article if the long-term care provider has not been paid by the State or the Medicaid managed care organization for services provided during the month on which the assessment is levied.
(c) If a long-term care provider fails to pay the full
amount of an assessment payment when due (including any extensions
granted under subsection (b)), there shall, unless waived by the
Illinois Department for reasonable cause, be added to the
assessment imposed by Section 5B-2 a
penalty assessment equal to the lesser of (i) 5% of the amount of
the assessment payment not paid on or before the due date plus 5% of the
portion thereof remaining unpaid on the last day of each month
thereafter or (ii) 100% of the assessment payment amount not paid on or
before the due date. For purposes of this subsection, payments
will be credited first to unpaid assessment payment amounts (rather than
to penalty or interest), beginning with the most delinquent assessment payments. Payment cycles of longer than 60 days shall be one factor the Director takes into account in granting a waiver under this Section.
(c-5) If a long-term care facility fails to file its assessment bill with payment, there shall, unless waived by the Illinois Department for reasonable cause, be added to the assessment due a penalty assessment equal to 25% of the assessment due. After July 1, 2013, no penalty shall be assessed under this Section if the Illinois Department does not provide a process for the electronic submission of the information required by subsection (a-5). (d) Nothing in this amendatory Act of 1993 shall be construed to prevent
the Illinois Department from collecting all amounts due under this Article
pursuant to an assessment imposed before the effective date of this amendatory
Act of 1993.
(e) Nothing in this amendatory Act of the 96th General Assembly shall be construed to prevent
the Illinois Department from collecting all amounts due under this Code
pursuant to an assessment, tax, fee, or penalty imposed before the effective date of this amendatory
Act of the 96th General Assembly. (f) No installment of the assessment imposed by Section 5B-2 shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under Section 5-5.2 of this Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under Section 5-5.2 of this Code and the waivers granted under 42 CFR 433.68, all installments otherwise due under Section 5B-4 prior to the date of notification shall be due and payable to the Department upon written direction from the Department within 90 days after issuance by the Comptroller of the payments required under Section 5-5.2 of this Code. (Source: P.A. 101-649, eff. 7-7-20; 102-1035, eff. 5-31-22.)
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(305 ILCS 5/5B-5) (from Ch. 23, par. 5B-5)
Sec. 5B-5. Annual reporting; penalty; maintenance of records.
(a) After December 31 of each year, and on or before
March 31 of the succeeding year, every long-term care provider subject to
assessment under this Article shall file a report with the Illinois
Department. The report shall be in a form and manner prescribed by the Illinois Department and shall state the revenue received by the long-term care provider, reported in such categories as may be required by the Illinois Department, and other reasonable information the Illinois Department requires for the administration of its responsibilities under this Code.
(b) If a long-term care provider operates or maintains
more than one long-term care facility in this State, the provider
may not file a single return covering all those long-term care
facilities, but shall file a separate return for each
long-term care facility and shall compute and pay the assessment
for each long-term care facility separately.
(c) Notwithstanding any other provision in this Article, in
the case of a person who ceases to operate or maintain a long-term
care facility in respect of which the person is subject to
assessment under this Article as a long-term care provider, the person shall file a final, amended return with the Illinois
Department not more than 90 days after the cessation reflecting
the adjustment and shall pay with the final return the
assessment for the year as so adjusted (to the extent not
previously paid). If a person fails to file a final amended return on a timely basis, there shall, unless waived by the Illinois Department for reasonable cause, be added to the assessment due a penalty assessment equal to 25% of the assessment due.
(d) Notwithstanding any other provision of this Article, a
provider who commences operating or maintaining a long-term care
facility that was under a prior ownership and remained licensed by the Department of Public Health shall notify the Illinois Department of any change in ownership regardless of percentage, and shall be responsible to immediately pay any prior amounts owed by the facility. In addition, beginning January 1, 2023, all providers operating or maintaining a long-term care facility shall notify the Illinois Department of all individual owners and any individuals or organizations that are part of a limited liability company with ownership of that facility and the percentage ownership of each owner. This ownership reporting requirement does not include individual shareholders in a publicly held corporation. Submission of the information as part of the Department's cost reporting requirements shall satisfy this requirement.
(e) The Department shall develop a procedure for sharing with a potential buyer of a facility information regarding outstanding assessments and penalties owed by that facility.
(f) In the case of a long-term care provider existing as a
corporation or legal entity other than an individual, the return
filed by it shall be signed by its president, vice-president,
secretary, or treasurer or by its properly authorized agent.
(g) If a long-term care provider fails to file its return
on or before the due date of the return,
there shall, unless waived by the Illinois Department for
reasonable cause, be added to the assessment imposed by Section
5B-2 a penalty assessment equal to 25%
of the assessment imposed for the year. After July 1, 2013, no penalty shall be assessed if the Illinois Department has not established a process for the electronic submission of information.
(h) Every long-term care provider subject to assessment
under this Article shall keep records and books that will
permit the determination of occupied bed days on a calendar year
basis. All such books and records shall be kept in the English
language and shall, at all times during business hours of the
day, be subject to inspection by the Illinois Department or its
duly authorized agents and employees.
(i) The Illinois Department shall establish a process for long-term care providers to electronically submit all information required by this Section no later than July 1, 2013. (Source: P.A. 102-1035, eff. 5-31-22.)
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(305 ILCS 5/5B-6) (from Ch. 23, par. 5B-6)
Sec. 5B-6.
Disposition of proceeds.
The Illinois Department
shall pay all moneys received from long-term care providers under
this Article into the Long-Term Care Provider Fund. Upon certification by
the Illinois Department to the State Comptroller of its intent to withhold
from a provider under Section 5B-7(b), the State Comptroller shall draw a
warrant on the treasury or other fund held by the State Treasurer, as
appropriate. The warrant shall state the amount for which the provider is
entitled to a warrant, the amount of the deduction, and the reason therefor
and shall direct the State Treasurer to pay the balance to the provider,
all in accordance with Section 10.05 of the State Comptroller Act. The
warrant also shall direct the State Treasurer to transfer the amount of the
deduction so ordered from the treasury or other fund into the Long-Term
Care Provider Fund.
(Source: P.A. 87-861.)
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(305 ILCS 5/5B-7) (from Ch. 23, par. 5B-7)
Sec. 5B-7.
Administration; enforcement provisions.
(a) To the extent practicable, the Illinois Department shall administer
and enforce this Article and collect the assessments, interest, and penalty
assessments imposed under this Article, using procedures employed in its
administration of this Code generally and, as it deems
appropriate, in a manner similar to that in which the Department
of Revenue administers and collects the retailers' occupation tax
under the Retailers' Occupation Tax Act ("ROTA"). Instead
of certificates of registration, the Illinois Department shall
establish and maintain a listing of all long-term care providers
appearing in the licensing records of the Department of Public
Health, which shall show each provider's name, principal place of business,
and the name and address of each long-term care facility operated or
maintained by the provider in this State. In addition, the following
provisions of the Retailers' Occupation Tax Act are incorporated by
reference into this Section, except that the Illinois Department
and its Director (rather than the Department of Revenue and its Director)
and every long-term care provider subject to assessment measured by
occupied bed days and to the return filing requirements of this Article
(rather than persons subject to retailers' occupation tax measured by gross
receipts from the sale of tangible personal property at retail and to the
return filing requirements of ROTA) shall have the powers, duties, and
rights specified in these ROTA provisions, as modified in this Section or
by the Illinois Department in a manner consistent with this Article and
except as manifestly inconsistent with the other provisions of this Article:
(1) ROTA, Section 4 (examination of return; notice of | ||
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(2) ROTA, Section 5 (failure to make return; failure | ||
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(3) ROTA, Section 5a (lien; attachment; termination; | ||
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(4) ROTA, Section 5b (State lien notices; State lien | ||
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(5) ROTA, Section 5c (liens; certificate of release).
(6) ROTA, Section 5d (Department not required to | ||
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(7) ROTA, Section 5e (foreclosure on liens; | ||
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(8) ROTA, Section 5f (demand for payment; levy and | ||
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(9) ROTA, Section 5g (sale of property; redemption).
(10) ROTA, Section 5j (sales on transfers outside | ||
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(11) ROTA, Section 6 (erroneous payments; credit or | ||
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(12) ROTA, Section 6a (claims for credit or refund).
(13) ROTA, Section 6b (tentative determination of | ||
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(14) ROTA, Section 6c (finality of tentative | ||
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(15) ROTA, Section 8 (investigations and hearings).
(16) ROTA, Section 9 (witness; immunity).
(17) ROTA, Section 10 (issuance of subpoenas; | ||
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(18) ROTA, Section 11 (information confidential; | ||
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(19) ROTA, Section 12 (rules and regulations; | ||
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(b) In addition to any other remedy provided for and without sending a
notice of assessment liability, the Illinois Department may collect an
unpaid assessment by withholding, as payment of the assessment,
reimbursements or other amounts otherwise payable by the Illinois
Department to the provider.
(Source: P.A. 87-861.)
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(305 ILCS 5/5B-8) (from Ch. 23, par. 5B-8)
Sec. 5B-8. Long-Term Care Provider Fund.
(a) There is created in the State Treasury the Long-Term
Care Provider Fund. Interest earned by the Fund shall be
credited to the Fund. The Fund shall not be used to replace any
moneys appropriated to the Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving and
disbursing moneys in accordance with this Article. Disbursements
from the Fund shall be made only as follows:
(1) For payments to nursing facilities, including | ||
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(1.5) For payments to managed care organizations as | ||
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(2) For the reimbursement of moneys collected by the | ||
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(3) For payment of administrative expenses incurred | ||
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(3.5) For reimbursement of expenses incurred by | ||
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(4) For payments of any amounts that are reimbursable | ||
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(5) For making transfers to the General Obligation | ||
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(6) For making transfers, at the direction of the | ||
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Disbursements from the Fund, other than transfers made pursuant to paragraphs (5) and (6) of this subsection, shall be by
warrants drawn by the State Comptroller upon receipt of vouchers
duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(1) All moneys collected or received by the Illinois | ||
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(2) All federal matching funds received by the | ||
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(3) Any interest or penalty levied in conjunction | ||
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(4) (Blank).
(5) All other monies received for the Fund from any | ||
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(Source: P.A. 102-1035, eff. 5-31-22.)
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(305 ILCS 5/5B-9) (from Ch. 23, par. 5B-9)
Sec. 5B-9.
Applicability.
The assessment imposed by Section 5B-2
shall cease to be imposed if the amount of matching federal funds
under Title XIX of the Social Security Act is eliminated or significantly
reduced on account of the assessment. Assessments imposed prior
thereto shall be disbursed in accordance with Section 5B-8 to the
extent federal matching is not reduced by the assessments, and
any remaining assessments shall be refunded to long-term care
providers in proportion to the amounts of the assessments paid by
them.
(Source: P.A. 87-861.)
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(305 ILCS 5/5B-10) (from Ch. 23, par. 5B-10)
Sec. 5B-10.
Severability.
If any clause, sentence, Section,
exemption, provision, or part of this Article or the application
thereof to any person or circumstance shall be adjudged to be
unconstitutional or otherwise invalid, the remainder of this
Article or its application to persons or circumstances other than
those to which it is held invalid shall not be affected thereby.
This Article V-B is intended to be separate from and independent
of Articles V-A and V-C, and the application and validity of
this Article V-B shall not be affected by the invalidity of one or
more of Articles V-A and V-C.
(Source: P.A. 87-861.)
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(305 ILCS 5/Art. V-C heading) ARTICLE V-C.
CARE PROVIDER FUNDING FOR PERSONS WITH A DEVELOPMENTAL DISABILITY
(Source: P.A. 99-143, eff. 7-27-15.) |
(305 ILCS 5/5C-1) (from Ch. 23, par. 5C-1)
Sec. 5C-1. Definitions. As used in this Article, unless the context
requires otherwise:
"Fund" means the Care Provider Fund for Persons with a Developmental Disability.
"Care facility for persons with a developmental disability" means an intermediate care
facility for the intellectually disabled within the meaning of Title XIX of the
Social Security Act, whether public or private and whether organized for
profit or not-for-profit, but shall not include any facility operated by
the State.
"Care provider for persons with a developmental disability" means a person conducting,
operating, or maintaining a facility for persons with a developmental disability. For
this purpose, "person" means any political subdivision of the State,
municipal corporation, individual, firm, partnership, corporation, company,
limited liability company, association, joint stock association, or trust,
or a receiver, executor, trustee, guardian or other representative
appointed by order of any court.
"Adjusted gross developmentally disabled care revenue" shall be computed
separately for each facility for persons with a developmental disability conducted,
operated, or maintained by a care provider for persons with a developmental disability, and
means the total revenue of the care provider for persons with a developmental disability for
inpatient residential services less contractual allowances and discounts on
patients' accounts, but does not include non-patient revenue from sources
such as contributions, donations or bequests, investments, day training
services, television and telephone service, and rental of facility space.
"Long-term care facility for persons under 22 years of age serving clinically complex residents" means a facility licensed by the Department of Public Health as a long-term care facility for persons under 22 meeting the qualifications of Section 5-5.4h of this Code. (Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-2) (from Ch. 23, par. 5C-2)
Sec. 5C-2. Assessment; no local authorization to tax.
(a) For the privilege of engaging in the occupation of care provider for persons with a developmental disability, an assessment is imposed upon each care provider for persons with a developmental disability in an amount equal to 6%, or the maximum allowed under federal regulation, whichever is less, of its adjusted
gross developmentally disabled care revenue for the prior State fiscal
year. Notwithstanding any provision of any other Act to the contrary, this
assessment shall be construed as a tax, but may not be added to the charges
of an individual's nursing home care that is paid for in whole, or in part,
by a federal, State, or combined federal-state medical care program, except
those individuals receiving Medicare Part B benefits solely.
(b) Nothing in this amendatory Act of 1995 shall be construed
to authorize any home rule unit or other unit of local government to license
for revenue or impose a tax or assessment upon a care provider for persons with a developmental disability or the occupation of care provider for persons with a developmental disability, or a tax
or assessment measured by the income or earnings of a care provider for persons with a developmental disability.
(c) Effective July 1, 2013, for the privilege of engaging in the occupation of long-term care facility for persons under 22 years of age serving clinically complex residents provider, an assessment is imposed upon each long-term care facility for persons under 22 years of age serving clinically complex residents provider in the same amount and upon the same conditions and requirements as imposed in Article V-B of this Code and a license fee is imposed in the same amount and upon the same conditions and requirements as imposed in Article V-E of this Code. Notwithstanding any provision of any other Act to the contrary, the assessment and license fee imposed by this subsection (c) shall be construed as a tax, but may not be added to the charges of an individual's nursing home care that is paid for in whole, or in part, by a federal, State, or combined federal-State medical care program, except for those individuals receiving Medicare Part B benefits solely. (Source: P.A. 98-651, eff. 6-16-14; 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-3) (from Ch. 23, par. 5C-3)
Sec. 5C-3. Payment of assessment; penalty.
(a) The assessment imposed by Section 5C-2 for a State
fiscal year shall be due and payable in quarterly installments,
each equalling one-fourth of the assessment for the year, on
September 30, December 31, March 31, and May 31 of the year.
(b) The Illinois Department is authorized to establish
delayed payment schedules for care providers for persons with a developmental disability that are unable to make installment payments when due
under this Section due to financial difficulties, as determined
by the Illinois Department.
(c) If a care provider for persons with a developmental disability fails to
pay the full amount of an installment when due (including any
extensions granted under subsection (b)), there shall, unless
waived by the Illinois Department for reasonable cause, be added
to the assessment imposed by Section 5C-2 for the State fiscal
year a penalty assessment equal to the lesser of (i) 5% of the
amount of the installment not paid on or before the due date plus
5% of the portion thereof remaining unpaid on the last day of
each month thereafter or (ii) 100% of the installment amount not
paid on or before the due date. For purposes of this subsection,
payments will be credited first to unpaid installment amounts
(rather than to penalty or interest), beginning with the most
delinquent installments.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-4) (from Ch. 23, par. 5C-4)
Sec. 5C-4. Reporting; penalty; maintenance of records.
(a) After June 30 of each State fiscal year, and on or before
September 30 of the succeeding State fiscal year, every care provider for persons with a developmental disability subject to assessment under this Article shall file
a return with the Illinois Department. The return shall report the
adjusted gross developmentally disabled care revenue from the State fiscal
year just ended and shall be utilized by the Illinois Department to
calculate the assessment for the State fiscal year commencing on the
preceding July 1. The return shall be on a form prepared by the Illinois
Department and shall state the following:
(1) The name of the care provider for persons with a | ||
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(2) The address of the care provider's principal | ||
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(3) The adjusted gross developmentally disabled care | ||
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(4) The amount of penalty due, if any.
(5) Other reasonable information the Illinois | ||
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(b) If a care provider for persons with a developmental disability operates
or maintains more than one care facility for persons with a developmental disability
in this State, the provider may not file a single return covering
all those care facilities for persons with a developmental disability, but shall file
a separate return for each care facility for persons with a developmental disability and shall compute and pay the assessment for each
care facility for persons with a developmental disability separately.
(c) Notwithstanding any other provision in this Article, a
person who ceases to conduct, operate, or maintain a
care facility for persons with a developmental disability in respect of which the
person is subject to assessment under this Article as a care provider for persons with a developmental disability, the assessment for the State fiscal year
in which the cessation occurs shall be adjusted by multiplying
the assessment computed under Section 5C-2 by a fraction, the
numerator of which is the number of months in the year during
which the provider conducts, operates, or maintains the
care facility for persons with a developmental disability and the denominator of
which is 12. The person shall file a final, amended return
with the Illinois Department not more than 90 days after the
cessation reflecting the adjustment and shall pay with the
final return the assessment for the year as so adjusted (to the
extent not previously paid).
(d) Notwithstanding any other provision of this Article, a
provider who commences conducting, operating, or maintaining a
care facility for persons with a developmental disability shall file an initial
return for the State fiscal year in which the commencement
occurs within 90 days thereafter and shall pay the assessment
computed under Section 5C-2 and subsection (e) in equal
installments on the due date of the return and on the regular
installment due dates for the State fiscal year occurring after
the due date of the initial return.
(e) Notwithstanding any other provision of this Article, in
the case of a care provider for persons with a developmental disability that did not
conduct, operate, or maintain a care facility for persons with a developmental disability throughout the prior State fiscal year, the assessment
for that State fiscal year shall be computed on the basis of
hypothetical adjusted gross developmentally disabled care revenue
for the prior year as determined by rules adopted by
the Illinois Department (which may be based on annualization of
the provider's actual revenues for a portion of the State fiscal
year, or revenues of a comparable facility for such year,
including revenues realized by a prior provider from the same
facility during such year).
(f) In the case of a care provider for persons with a developmental disability
existing as a corporation or legal entity other than an
individual, the return filed by it shall be signed by its
president, vice-president, secretary, or treasurer or by its
properly authorized agent.
(g) If a care provider for persons with a developmental disability fails to
file its return for a State fiscal year on or before the due date
of the return, there shall, unless waived by the Illinois
Department for reasonable cause, be added to the assessment
imposed by Section 5C-2 for the State fiscal year a penalty
assessment equal to 25% of the assessment imposed for the year.
(h) Every care provider for persons with a developmental disability subject to
assessment under this Article shall keep records and books
that will permit the determination of adjusted gross developmentally disabled care revenue on a State fiscal year
basis. All such books and records shall be kept in the English
language and shall, at all times during business hours of the
day, be subject to inspection by the Illinois Department or its
duly authorized agents and employees.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-5) (from Ch. 23, par. 5C-5)
Sec. 5C-5. Disposition of proceeds. The Illinois Department
shall pay all moneys received from care providers for persons with a developmental disability under this Article into the Care
Provider Fund for Persons with a Developmental Disability. Upon certification by the Illinois Department
to the State Comptroller of its intent to withhold from a
provider under Section 5C-6(b), the State Comptroller shall
draw a warrant on the treasury or other fund held by the State
Treasurer, as appropriate. The warrant shall state the
amount for which the provider is entitled to a warrant, the
amount of the deduction, and the reason therefor and shall direct the
State Treasurer to pay the balance to the provider, all in
accordance with Section 10.05 of the State Comptroller Act. The warrant
also shall direct the State Treasurer to transfer the amount of the
deduction so ordered from the treasury or other fund into the
Care Provider Fund for Persons with a Developmental Disability.
(Source: P.A. 98-463, eff. 8-16-13; 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-6) (from Ch. 23, par. 5C-6)
Sec. 5C-6. Administration; enforcement provisions.
(a) To the extent practicable, the Illinois Department shall administer and
enforce this Article and collect the assessments, interest, and
penalty assessments imposed under this Article, using procedures
employed in its administration of this Code generally and, as it deems
appropriate, in a manner similar to that in which the Department
of Revenue administers and collects the retailers' occupation tax
pursuant to the Retailers' Occupation Tax Act ("ROTA"). Instead
of certificates of registration, the Illinois Department shall
establish and maintain a listing of all care providers for persons with a developmental disability appearing in the licensing records of the
Department of Public Health, which shall show each provider's
name, principal place of business, and the name and address of
each care facility for persons with a developmental disability operated or maintained by the
provider in this State. In addition, the following Retailers' Occupation
Tax Act provisions are incorporated by reference into this Section, except
that the Illinois Department and its Director (rather than the Department
of Revenue and its Director) and every care provider for persons with a developmental disability subject to assessment measured by adjusted gross developmentally
disabled care revenue and to the return filing requirements of this Article
(rather than persons subject to retailers' occupation tax measured by gross
receipts from the sale of tangible personal property at retail and to the
return filing requirements of ROTA) shall have the powers, duties, and
rights specified in these ROTA provisions, as modified in this Section or
by the Illinois Department in a manner consistent with this Article and
except as manifestly inconsistent with the other provisions of this Article:
(1) ROTA, Section 4 (examination of return; notice of | ||
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(2) ROTA, Section 5 (failure to make return; failure | ||
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(3) ROTA, Section 5a (lien; attachment; termination; | ||
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(4) ROTA, Section 5b (State lien notices; State lien | ||
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(5) ROTA, Section 5c (liens; certificate of release).
(6) ROTA, Section 5d (Department not required to | ||
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(7) ROTA, Section 5e (foreclosure on liens; | ||
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(8) ROTA, Section 5f (demand for payment; levy and | ||
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(9) ROTA, Section 5g (sale of property; redemption).
(10) ROTA, Section 5j (sales on transfers outside | ||
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(11) ROTA, Section 6 (erroneous payments; credit or | ||
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(12) ROTA, Section 6a (claims for credit or refund).
(13) ROTA, Section 6b (tentative determination of | ||
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(14) ROTA, Section 6c (finality of tentative | ||
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(15) ROTA, Section 8 (investigations and hearings).
(16) ROTA, Section 9 (witness; immunity).
(17) ROTA, Section 10 (issuance of subpoenas; | ||
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(18) ROTA, Section 11 (information confidential; | ||
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(19) ROTA, Section 12 (rules and regulations; | ||
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(b) In addition to any other remedy provided for and without sending a
notice of assessment liability, the Illinois Department may collect an
unpaid assessment by withholding, as payment of the assessment,
reimbursements or other amounts otherwise payable by the Illinois
Department to the provider.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-7) (from Ch. 23, par. 5C-7)
Sec. 5C-7. Care Provider Fund for Persons with a Developmental Disability.
(a) There is created in the State Treasury the
Care Provider Fund for Persons with a Developmental Disability. Interest earned by the Fund shall be credited to the
Fund. The Fund shall not be used to replace any moneys appropriated to the
Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving and
disbursing assessment moneys in accordance with this Article.
Disbursements from the Fund shall be made only as follows:
(1) For payments to intermediate care facilities for | ||
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(2) For the reimbursement of moneys collected by the | ||
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(3) For payment of administrative expenses incurred | ||
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(4) For payments of any amounts which are | ||
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(5) For making transfers to the General Obligation | ||
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(6) For making refunds as required under Section | ||
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Disbursements from the Fund, other than transfers to the
General Obligation Bond Retirement and Interest Fund, shall be by
warrants drawn by the State Comptroller upon receipt of vouchers
duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(1) All moneys collected or received by the Illinois | ||
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(2) All federal matching funds received by the | ||
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(3) Any interest or penalty levied in conjunction | ||
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(4) Any balance in the Medicaid Care Provider for | ||
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(5) All other moneys received for the Fund from any | ||
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(Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-8) (from Ch. 23, par. 5C-8)
Sec. 5C-8. Applicability. The assessment imposed by Section 5C-2
shall cease to be imposed if the amount of matching federal funds
under Title XIX of the Social Security Act is eliminated or significantly
reduced on account of the assessment. Assessments imposed prior
thereto shall be disbursed in accordance with Section 5C-7 to the
extent federal matching is not reduced by the assessments, and
any remaining assessments shall be refunded to care providers for persons with a developmental disability in proportion to the amounts paid by
them.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/5C-9) (from Ch. 23, par. 5C-9)
Sec. 5C-9.
Severability.
If any clause, sentence, Section,
exemption, provision, or part of this Article or the application
thereof to any person or circumstance shall be adjudged to be
unconstitutional or otherwise invalid the remainder of this
Article or its application to persons or circumstances other than
those to which it is held invalid shall not be affected thereby.
This Article V-C is intended to be separate from and independent
of Articles V-A and V-B, and the application and validity of
this Article V-C shall not be affected by the invalidity of one or
more of Articles V-A and V-B.
(Source: P.A. 87-861.)
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(305 ILCS 5/5C-10) Sec. 5C-10. Adjustments. For long-term care facilities for persons under 22 years of age serving clinically complex residents previously classified as care facilities for persons with a developmental disability under this Article, the Department shall refund any amounts paid under this Article in State fiscal year 2014 by the end of State fiscal year 2015 with at least half the refund amount being made prior to December 31, 2014. The amounts refunded shall be based on amounts paid by the facilities to the Department as the assessment under subsection (a) of Section 5C-2 less any assessment and license fee due for State fiscal year 2014.
(Source: P.A. 98-651, eff. 6-16-14; 99-143, eff. 7-27-15.) |
(305 ILCS 5/Art. V-D heading) ARTICLE V-D.
EXEMPTION OF RURAL HOSPITALS
(Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/5D-1) (from Ch. 23, par. 5D-1)
Sec. 5D-1.
(Repealed).(Source: P.A. 89-21, eff. 7-1-95. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/5D-2) (from Ch. 23, par. 5D-2)
Sec. 5D-2.
(Repealed).
(Source: P.A. 88-88. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/Art. V-E heading) ARTICLE V-E. NURSING HOMELICENSE FEE(Repealed internally, eff. 7-1-24.) |
(305 ILCS 5/Art. V-F heading) ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT INITIATIVE (MMAI) NURSING HOME RESIDENTS' MANAGED CARE RIGHTS LAW
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-1) Sec. 5F-1. Short title. This Article may be referred to as the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-5) Sec. 5F-5. Findings. The General Assembly finds that elderly Illinoisans residing in a nursing home have the right to: (1) quality health care regardless of the payer; (2) receive medically necessary care prescribed by | ||
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(3) a simple appeal process when care is denied; and (4) make decisions about their care and where they | ||
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(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-10) Sec. 5F-10. Scope. This Article applies to policies and contracts amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 98th General Assembly for the nursing home component of the Medicare-Medicaid Alignment Initiative and the Managed Long-Term Services and Support Program. This Article does not diminish a managed care organization's duties and responsibilities under other federal or State laws or rules adopted under those laws and the 3-way Medicare-Medicaid Alignment Initiative contract and the Managed Long-Term Services and Support Program contract.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.) |
(305 ILCS 5/5F-15) Sec. 5F-15. Definitions. As used in this Article: "Appeal" means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 CFR 422.566(b). These procedures include reconsiderations by the managed care organization and, if necessary, an independent review entity as provided by the Health Carrier External Review Act, hearings before administrative law judges, review by the Medicare Appeals Council, and judicial review. "Demonstration Project" means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project. "Department" means the Department of Healthcare and Family Services. "Enrollee" means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. "Health care services" means the diagnosis, treatment, and prevention of disease and includes medication, primary care, nursing or medical care, mental health treatment, psychiatric rehabilitation, memory loss services, physical, occupational, and speech rehabilitation, enhanced care, medical supplies and equipment and the repair of such equipment, and assistance with activities of daily living. "Managed care organization" or "MCO" means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. "Medical professional" means a physician, physician assistant, or nurse practitioner. "Medically necessary" means health care services that a medical professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms, and that are: (i) in accordance with the generally accepted standards of medical practice; (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, a medical professional, other health care provider, caregiver, family member, or other interested party. "Nursing home" means a facility licensed under the Nursing Home Care Act. "Nurse practitioner" means an individual properly licensed as a nurse practitioner under the Nurse Practice Act. "Physician" means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987. "Physician assistant" means an individual properly licensed under the Physician Assistant Practice Act of 1987. "Resident" means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. "RAI Manual" means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services. "Resident's representative" means a person designated in writing by a resident to be the resident's representative or the resident's guardian, as described by the Nursing Home Care Act. "SNFist" means a medical professional specializing in the care of individuals residing in nursing homes employed by or under contract with a MCO. "Transition period" means a period of time immediately following enrollment into the Demonstration Project or an enrollee's movement from one managed care organization to another managed care organization or one care setting to another care setting.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-20) Sec. 5F-20. Network adequacy. (a) Every managed care organization shall allow every nursing home in its service area an opportunity to be a network contracted facility at the plan's standard terms, conditions, and rates. Either party may opt to limit the contract to existing residents only. (b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met: (1) the quality standards are made known to the | ||
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(2) the quality standards can be objectively | ||
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(3) the nursing home is measured on at least a | ||
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(4) a nursing home that the MCO has determined did | ||
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(5) the Department may attempt to mediate a dispute | ||
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(c) A managed care organization may terminate or refuse to renew a contract with a nursing home for a material breach of the contract, including, but not limited to, failure to grant reasonable and timely access to the MCO's care coordinators, SNFists and other providers, termination from the Medicare or Medicaid program, or revocation of license.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-25) Sec. 5F-25. Care coordination. Care coordination provided to all enrollees in the Demonstration Project shall conform to the following requirements: (1) care coordination services shall be | ||
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(2) all enrollees in the Demonstration Project shall | ||
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(3) decisions shall be based on the enrollee's best | ||
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(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-30) Sec. 5F-30. Continuity of care. When a nursing home resident first transitions to a managed care organization from the fee-for-service system or from another managed care organization, the managed care organization shall honor the existing care plan and any necessary changes to that care plan until the MCO has completed a comprehensive assessment and new care plan, to the extent such services are covered benefits under the contract, which shall be consistent with the requirements of the RAI Manual. When an enrollee of a managed care organization is moving from a community setting to a nursing home, and the MCO is properly notified of the proposed admission by a network nursing home, and the managed care organization fails to participate in developing a care plan within the time frames required by nursing home regulations, the MCO must honor a care plan developed by the nursing home until the MCO has completed a comprehensive assessment and a new care plan to the extent such services are covered benefits under the contract, consistent with the requirements of the RAI Manual. A nursing home shall have the ability to refuse admission of an enrollee for whom care is required that the nursing home determines is outside the scope of its license and healthcare capabilities.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-31) Sec. 5F-31. Patient credit files; denials of claims. To reduce the number of claim denials resulting from coverage plan errors, the Department shall provide each nursing home enrolled in one or more Medicaid managed care networks with the corresponding patient credit file at the same time the Department provides the files to the managed care organization.
(Source: P.A. 100-1085, eff. 1-1-19.) |
(305 ILCS 5/5F-32) Sec. 5F-32. Non-emergency prior approval and appeal. (a) MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year from nursing home residents, physicians, or providers. If a response is not provided within 24 hours of the request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO's contract in the Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO. In a non-emergency situation, notwithstanding any provisions in State law to the contrary, in the event a resident's physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO. If an enrollee, physician, or provider requests an expedited appeal pursuant to 42 CFR 438.410, the MCO shall notify the individual filing the appeal, whether it is the enrollee, physician, or provider, within 24 hours after the submission of the appeal of all information from the enrollee, physician, or provider that the MCO requires to evaluate the appeal. The MCO shall notify the individual filing the appeal of the MCO's decision on an expedited appeal within 24 hours after receipt of the required information. (b) While the appeal is pending or if the ordered service, treatment, or test is denied after appeal, the Department of Public Health may not cite the nursing home for failure to provide the ordered service, treatment, or test. The nursing home shall not be liable or responsible for an injury in any regulatory proceeding for the following: (1) failure to follow the appealed or denied order; | ||
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(2) injury to the extent it was caused by the delay | ||
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Provided however, a nursing home shall continue to monitor, document, and ensure the patient's safety. Nothing in this subsection (b) is intended to otherwise change the nursing home's existing obligations under State and federal law to appropriately care for its residents.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.) |
(305 ILCS 5/5F-33) Sec. 5F-33. Payment of claims. (a) Clean claims, as defined by the Department, submitted by a provider to a managed care organization in the form and manner requested by the managed care organization shall be reviewed and paid within 30 days of receipt. (b) A managed care organization must provide a status update within 60 days of the submission of a claim. (c) A claim that is rejected or denied shall clearly state the reason for the rejection or denial in sufficient detail to permit the provider to understand the justification for the action. (d) The Department shall work with stakeholders, including, but not limited to, managed care organizations and nursing home providers, to train them on the application of standardized codes for long-term care services. (e) Managed care organizations shall provide a manual clearly explaining billing and claims payment procedures, including points of contact for provider services centers, within 15 days of a provider entering into a contract with a managed care organization. The manual shall include all necessary coding and documentation requirements. Providers under contract with a managed care organization on the effective date of this amendatory Act of the 99th General Assembly shall be provided with an electronic copy of these requirements within 30 days of the effective date of this amendatory Act of the 99th General Assembly. Any changes to these requirements shall be delivered electronically to all providers under contract with the managed care organization 30 days prior to the effective date of the change.
(Source: P.A. 99-719, eff. 1-1-17.) |
(305 ILCS 5/5F-35) Sec. 5F-35. Reimbursement. The Department shall provide each managed care organization with the quarterly facility-specific RUG-IV nursing component per diem along with any add-ons for enhanced care services, support component per diem, and capital component per diem effective for each nursing home under contract with the managed care organization.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-40) Sec. 5F-40. Contractual requirements. (a) Every contract shall contain a clause for termination consistent with the Managed Care Reform and Patient Rights Act providing nursing homes the ability to terminate the contract. (b) All changes to the contract by the MCO shall be preceded by 30 days' written notice sent to the nursing home.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-45) Sec. 5F-45. Prohibition. No managed care organization or contract shall contain any provision, policy, or procedure that limits, restricts, or waives any rights set forth in this Article or is expressly prohibited by this Article. Any such policy or procedure is void and unenforceable.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/Art. V-G heading) ARTICLE V-G. SUPPORTIVE LIVING FACILITY FUNDING(Repealed by P.A. 103-593)(Source: P.A. 103-154, eff. 6-30-23. Repealed by P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/Art. V-H heading) ARTICLE V-H. MANAGED CARE ORGANIZATION PROVIDER ASSESSMENT
(Source: P.A. 103-154, eff. 6-30-23.) |
(305 ILCS 5/5H-1) Sec. 5H-1. Definitions. As used in this Article: "Base year" means the 12-month period from January 1, 2023 to December 31, 2023. "Department" means the Department of Healthcare and Family Services. "Federal employee health benefit" means the program of health benefits plans, as defined in 5 U.S.C. 8901, available to federal employees under 5 U.S.C. 8901 to 8914. "Fund" means the Healthcare Provider Relief Fund. "Managed care organization" means an entity operating under a certificate of authority issued pursuant to the Health Maintenance Organization Act or as a Managed Care Community Network pursuant to Section 5-11 of this Code. "Medicaid managed care organization" means a managed care organization under contract with the Department to provide services to recipients of benefits in the medical assistance program pursuant to Article V of this Code, the Children's Health Insurance Program Act, or the Covering ALL KIDS Health Insurance Act. It does not include contracts the same entity or an affiliated entity has for other business. "Medicare" means the federal Medicare program established under Title XVIII of the federal Social Security Act. "Member months" means the aggregate total number of months all individuals are enrolled for coverage in a Managed Care Organization during the base year. Member months are determined by the Department for Medicaid Managed Care Organizations based on enrollment data in its Medicaid Management Information System and by the Department of Insurance for other Managed Care Organizations based on required filings with the Department of Insurance. Member months do not include months individuals are enrolled in a Limited Health Services Organization, including stand-alone dental or vision plans, a Medicare Advantage Plan, a Medicare Supplement Plan, a Medicaid Medicare Alignment Initiate Plan pursuant to a Memorandum of Understanding between the Department and the Federal Centers for Medicare and Medicaid Services or a Federal Employee Health Benefits Plan.(Source: P.A. 102-558, eff. 8-20-21; 103-593, eff. 6-7-24.) |
(305 ILCS 5/5H-2) Sec. 5H-2. Federal waivers. The Department shall request a waiver from the federal Centers for Medicare and Medicaid Services of the broad-based and uniformity provisions of Section 1903(w)(3)(B) and (C) of Title XIX of the Social Security Act, 42 U.S.C. 1396b, relating to the assessment imposed under this Article. The assessment required pursuant to Section 5H-3 shall not be due and payable until such waiver has been approved and all other federal requirements necessary to obtain federal financial participation have been approved by the Centers for Medicare and Medicaid Services.
(Source: P.A. 101-9, eff. 6-5-19.) |
(305 ILCS 5/5H-3) Sec. 5H-3. Managed care assessment. (a) There is imposed upon managed care organization member months an assessment, calculated on base year data, as set forth below for the appropriate tier: (1) Tier 1: $78.90 per member month. (2) Tier 2: $1.40 per member month. (3) Tier 3: $2.40 per member month. (b) The tiers are established as follows: (1) Tier 1 includes the first 4,195,000 member months | ||
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(2) Tier 2 includes member months over 4,195,000 in a | ||
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(3) Tier 3 includes member months during the base | ||
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(c) For State fiscal year 2020, and for each State fiscal year thereafter, the Department may adjust rates or tier parameters or both in order to maximize the revenue generated by the assessment consistent with federal regulations and to meet federal statistical tests necessary for federal financial participation. Any upward adjustment to the Tier 3 rate shall be the minimum necessary to meet federal statistical tests.(Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/5H-4) Sec. 5H-4. Payment of assessment. (a) The assessment payable pursuant to Section 5H-3 shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the first State business day of each month. (b) If the approval of the waivers required under Section 5H-2 is delayed beyond the start of State fiscal year 2020, then the first installment shall be due on the first business day of the first month that begins more than 15 days after the date of such approval. In the event approval results in installments beginning after July 1, 2019, the amount of each installment for that fiscal year shall equal the full amount of the annual assessment divided by the number of payments that will be paid in fiscal year 2020. (c) The Department shall notify each managed care organization of its annual fiscal year 2020 assessment and the installment due dates no later than 30 days prior to the first installment due date and the annual assessment and due dates for each subsequent year at least 30 days prior to the start of each fiscal year. (d) Proceeds from the assessment levied pursuant to Section 5H-3 shall be deposited into the Fund; provided, however, that proceeds from the assessment levied pursuant to Section 5H-3 upon a county provider as defined in Section 15-1 of this Code shall instead be deposited directly into the County Provider Trust Fund.
(Source: P.A. 101-9, eff. 6-5-19; 101-636, eff. 6-10-20.) |
(305 ILCS 5/5H-5) Sec. 5H-5. Liability or resultant entities. In the event of a merger, acquisition, or any similar transaction involving entities subject to the assessment under this Article, the resultant entity shall be responsible for the full amount of the assessment for all entities involved in the transaction with the member months allotted to tiers as they were prior to the transaction and no member months shall change tiers as a result of any transaction. A managed care organization that ceases doing business in the State during any fiscal year shall be liable only for the monthly installments due in months that it operated in the State. The Department shall by rule establish a methodology to set the assessment base member months for a managed care organization that begins operating in the State at any time after 2018. Nothing in this Section shall be construed to limit authority granted in subsection (c) of Section 5H-3.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.) |
(305 ILCS 5/5H-6) Sec. 5H-6. Recordkeeping; penalties. (a) A managed care organization that is liable for the assessment under this Article shall keep accurate and complete records and pertinent documents as may be required by the Department. Records required by the Department shall be retained for a period of 4 years after the assessment imposed under this Act to which the records apply is due or as otherwise provided by law. The Department or the Department of Insurance may audit all records necessary to ensure compliance with this Article and make adjustments to assessment amounts previously calculated based on the results of any such audit. (b) If a managed care organization fails to make a payment due under this Article in a timely fashion, it shall pay an additional penalty of 5% of the amount of the installment not paid on or before the due date, or any grace period granted, plus 5% of the portion thereof remaining unpaid on the last day of each 30-day period thereafter. The Department is authorized to grant grace periods of up to 30 days upon request of a managed care organization for good cause due to financial or other difficulties, as determined by the Department. If a managed care organization fails to make a payment within 60 days after the due date the Department shall additionally impose a contractual sanction allowed against a Medicaid managed care organization and may terminate any such contract. The Department of Insurance shall take action against the certificate of authority of a non-Medicaid managed care organization that fails to pay an installment within 60 days after the due date.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.) |
(305 ILCS 5/5H-7) Sec. 5H-7. Rulemaking. The Department may by rule modify or make adjustments to any methodology, assessment amount, assessment tier, or other similar provision specified in this Article, including broadening the tax base in subsection (a) of Section 5H-3, to the extent necessary to meet the requirements of federal law or regulations, obtain federal approval, or to ensure federal financial participation is available. However, upward adjustments to Tier 3 rates shall be the minimum necessary to meet federal statistical tests to receive federal financial participation. The Department shall adopt rules to implement this Article under the Illinois Administrative Procedure Act.
(Source: P.A. 101-9, eff. 6-5-19.) |
(305 ILCS 5/5H-8) Sec. 5H-8. Duties of the Department. (a) The Department shall ensure that rates to Medicaid managed care organizations are actuarially sound including appropriate incorporation of assessments under this Article, other taxes and administrative expenses, including standardization of processes, and cost of medical care. (b) The Department shall pay to each Medicaid managed care organization the amount required to be included in its rates due to the assessment under this Article in order to ensure actuarial soundness within 10 business days of receipt of each assessment payment from the Medicaid managed care organization. The Department shall extend the deadline for any assessment payment due after the initial assessment payment if the payment to the managed care organizations under this subsection for the previous assessment payment has not been paid. Such extension shall extend until 7 business days after receipt by the managed care organization of the late payment under this subsection. (c) Reimbursement of assessments paid under this Article shall not be required to count as revenue towards any calculation of the managed care organization's medical loss ratio, net worth, risk based capital or other deposit requirements as may otherwise be required under the Insurance Code. Such reimbursements will be considered revenue in calculating the 6% limit under 42 U.S.C. 433.68(f)(3). (d) The Department shall include in its annual report, beginning with its fiscal year 2020 report, and every year thereafter, information on the revenues collected from this assessment, the federal funds drawn based on those revenues, the rates set in Section 5H-3 or any alterations thereof by administrative rule, and other impacts this gross revenue has had on the Medicaid program.
(Source: P.A. 101-9, eff. 6-5-19.) |
(305 ILCS 5/Art. VI heading) ARTICLE VI.
GENERAL ASSISTANCE
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(305 ILCS 5/6-1) (from Ch. 23, par. 6-1)
Sec. 6-1. Eligibility requirements. Financial aid in meeting basic
maintenance requirements shall be given under this Article to
or in behalf of persons who meet the eligibility conditions of Sections
6-1.1 through 6-1.10.
In addition, each unit of local government subject to this Article shall
provide persons receiving financial aid in meeting basic maintenance
requirements with financial aid for either (a) necessary treatment, care, and
supplies required because of illness or disability, or (b) acute medical
treatment, care, and supplies only. If a local governmental unit elects to
provide financial aid for acute medical treatment, care, and supplies only, the
general types of acute medical treatment, care, and supplies for which
financial
aid is provided shall be specified in the general assistance rules of the local
governmental unit, which rules shall provide that financial aid is provided, at
a minimum, for acute medical treatment, care, or supplies necessitated by a
medical condition for which prior approval or authorization of medical
treatment, care, or supplies is not required by the general assistance rules
of the Illinois Department.
(Source: P.A. 100-538, eff. 1-1-18.)
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(305 ILCS 5/6-1.1) (from Ch. 23, par. 6-1.1)
Sec. 6-1.1.
Residence.)
If it appears that an applicant is not a resident of this State but that
he will suffer great
hardship and privation unless general assistance is provided, general assistance
may be given for such
temporary period of time as the need therefor exists. If the applicant
is a resident of some place
within the United States charged by law with the support of its needy residents,
upon the request
of the applicant, transportation to such place may be provided, together
with support during the
journey and temporary support pending transportation.
If the person is a resident of this State but has not resided in the governmental
unit in
which he makes application for a continuous period of 6 months, the governmental
unit in which he last so
resided shall be charged with providing the necessary aid until the person
has resided in the governmental
unit to which he has moved for a continuous period of 6 months. The governmental
unit to which he has
moved shall thereupon become responsible for providing the necessary aid,
whether or not he has
received general assistance during the 6 months period. The local governmental
unit to which application
is made shall determine promptly whether or not the applicant meets the
6 months residence requirement. Pending
the determination, general assistance shall be provided if the person is
otherwise eligible as a needy
person. If it is determined that he is a resident of another governmental
unit, notice shall be given
that unit. Upon receipt of such notice that unit shall furnish the necessary
aid until the person
has established a residence in the governmental unit in which he has made
application. On failure or refusal
of the unit of residence to provide aid, the unit to which application is
made shall provide the aid
which shall be recoverable against the unit of residence by appropriate civil action.
(Source: P.A. 79-353.)
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(305 ILCS 5/6-1.2) (from Ch. 23, par. 6-1.2)
Sec. 6-1.2. Need. Income available to the person, when added to
contributions in money, substance, or services from other sources,
including contributions from legally responsible relatives, must be
insufficient to equal the grant amount established by Department regulation
(or by local governmental unit in units which do not receive State funds)
for such a person.
In determining income to be taken into account:
(1) The first $75 of earned income in income | ||
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(2) For income assistance units not comprised | ||
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"Earned income" means money earned in self-employment or wages, salary,
or commission for personal services performed as an employee. The eligibility
of any applicant for or recipient of public aid under this Article is not
affected by the payment of any grant under the "Senior Citizens and Persons with Disabilities Property Tax Relief Act", any
refund
or payment of the federal Earned Income Tax Credit, any rebate authorized under Section 2201(a) of the Coronavirus Aid, Relief, and Economic Security Act (Public Law 116-136) or under any other federal economic stimulus program created in response to the COVID-19 emergency, or any distributions or
items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
(Source: P.A. 101-632, eff. 6-5-20.)
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(305 ILCS 5/6-1.3) (from Ch. 23, par. 6-1.3)
Sec. 6-1.3. Utilization of aid available under other provisions of
Code. The person must have been determined ineligible for aid under the
federally funded programs to aid refugees and Articles
III, IV or V. Nothing in this Section shall prevent the use of General
Assistance funds to pay any portion of the costs of care and maintenance
in a residential substance use disorder treatment program licensed by the Department
of Human Services, or in a County
Nursing Home,
or in a private nursing home, retirement home or other facility for
the care of the elderly, of a person otherwise eligible to receive General
Assistance except for the provisions of this paragraph.
A person otherwise eligible for aid under the federally funded programs
to aid refugees or Articles III, IV or V who
fails or refuses to comply with provisions of this Code or other laws, or
rules and regulations of the Illinois Department, which would qualify him
for aid under those programs or Articles, shall not receive General
Assistance under this Article nor shall any of his dependents whose
eligibility is contingent upon such compliance receive General Assistance.
Persons and families who are ineligible for aid under Article IV due to
having received benefits under Article IV for any maximum time limits set under
the Illinois Temporary Assistance for Needy Families (TANF) Plan shall not be
eligible for General Assistance under this Article unless the Illinois
Department or the local governmental unit, by rule, specifies that those
persons
or families may be eligible.
(Source: P.A. 100-759, eff. 1-1-19; 100-863, eff. 8-14-18.)
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(305 ILCS 5/6-1.3a) (from Ch. 23, par. 6-1.3a)
Sec. 6-1.3a.
Residents of public institutions.
Residents of municipal,
county, state or national institutions for persons with mental illness or
persons with a developmental disability or for the tuberculous, or residents of
a home or other institution maintained by such governmental bodies when not in
need of institutional care because of sickness, convalescence, infirmity, or
chronic illness, and inmates of penal or correctional institutions maintained
by such governmental bodies, may qualify for aid under this Article only after
they have ceased to be residents or inmates.
A person shall not be deemed a resident of a state institution for persons
with mental illness or persons with a developmental disability within the
meaning of this Section if he has been conditionally discharged by the
Department of Mental Health and Developmental Disabilities or the Department
of Human Services (acting as successor to the Department of Mental Health and
Developmental Disabilities) and is no longer residing in the institution.
Recipients of benefits under this Article who become residents of such
institutions shall be permitted a period of up to 30 days in such institutions
without suspension or termination of eligibility. Benefits for which such
person is eligible shall be restored, effective on the date of discharge or
release, for persons who are residents of institutions. Within a reasonable
time after the discharge of a person who was a resident of an institution, the
Department shall redetermine the eligibility of such person.
The Department shall provide for procedures to expedite the determination of
ability to engage in employment of persons scheduled to be discharged from
facilities operated by the Department.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/6-1.4) (from Ch. 23, par. 6-1.4)
Sec. 6-1.4.
Registration for and Acceptance of Employment.
A person who is able to engage in employment, including dependent
members of his family age 16 or over not in regular attendance in school as
defined in Section 4-1.1, who is unemployed or employed for less than the
full working time for the occupation in which he is engaged, must register
for and accept bona fide offers of employment, as provided in Section
11-20. The local governmental unit shall
determine, pursuant to rules and regulations, sanctions for persons failing
to comply with requirements under this Section. In addition to any sanctions
provided for in Section 11-20, sanctions may include the loss of eligibility
to receive aid under this Article for up to 90 days.
(Source: P.A. 85-114.)
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(305 ILCS 5/6-1.5) (from Ch. 23, par. 6-1.5)
Sec. 6-1.5.
Participation in educational and vocational training programs.
A person for whom education and training is suitable must participate in
the educational and vocational training programs established under Section
9-5 of Article IX.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/6-1.6) (from Ch. 23, par. 6-1.6)
Sec. 6-1.6.
Acceptance of Assignment to Job Search, Training and Work
Programs. A person for whom the job search, training and work programs
established under Section 9-6 of Article IX are applicable must accept
assignment to such programs. In conducting job search programs, the
Illinois Department and the local governmental unit shall by rule specify a
reasonable minimum number of employer contacts, and methods of
documentation, to be made by program participants each month and shall
determine, pursuant to rules and regulations, sanctions for persons failing
to comply with the requirements under Section 9-6. However, no
participant shall be sanctioned for failure to satisfy job search
requirements prior to a full assessment of his job readiness and
employability. No participant shall be sanctioned for failure to satisfy
the minimum number of employer contacts if he has made a good faith effort
to comply. The Illinois Department and local governmental units shall
provide payment for transportation and other necessary expenses to comply
with the requirements of such programs, as defined by rule. Sanctions
shall not apply to participants who are not provided with such payments.
Such payments to participants shall be provided in advance of participant
program compliance by the Illinois Department and may be provided in
advance of such compliance by the local governmental unit. Sanctions
may include the loss of eligibility to receive aid
under this Article for a period of time of up to 3 months.
(Source: P.A. 85-114.)
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(305 ILCS 5/6-1.7) (from Ch. 23, par. 6-1.7)
Sec. 6-1.7. A recipient of financial aid under this Article, which money
or vendor payment is made by a local governmental unit which administers aid
under this Article and is not a County Department, who is required under
Section 6-1.4 to register for and accept bona fide offers of employment
as provided in Section 11-20 but is not required to participate in a job
search, training and work program under Section 9-6, must also register
for work with such local governmental unit and must perform work without
compensation for a taxing district or private not-for-profit
organization as provided in this Section.
A local governmental unit which administers aid under this Article shall
maintain a roster of the persons who have registered for work in such local
governmental unit, and shall assure that such roster is available for the
inspection of the governing authorities of all taxing districts or
private not-for-profit organizations, or the
duly authorized agents thereof, for the selection of possible workers. Each
such local governmental unit shall cause persons, who are selected by a
taxing district or private not-for-profit organization to perform work,
to be notified at least 24 hours in
advance of the time the work is to begin.
Each such local governmental unit shall assure that the following additional
requirements are complied with:
(a) The taxing district or private not-for-profit organization may
not use a person selected to work under this
Section to replace a regular employee.
(b) The work to be performed for the taxing district or private
not-for-profit organization must be reasonably
related to the skills or interests of the recipient.
(c) The maximum number of hours such work may be performed is 8 hours
per day and 40 hours per week.
(d) The recipient shall be provided or compensated for transportation
to and from the work location.
(e) The person selected to work under this Section shall receive credit
against his or her monthly benefits under this Article, based on the State or federal
minimum wage rate, whichever is higher, for the work performed.
However, a taxing district or private not-for-profit organization
using the services of such recipient must pay
the recipient at least the State or federal minimum wage, whichever is higher, after such recipient has
received credit by the Illinois Department equal to the amount of financial
aid received under this Article, or the recipient shall be discharged.
Moneys made available for public aid purposes under this Article may be
expended to purchase worker's compensation insurance or to pay worker's
compensation claims.
For the purposes of this Section, "taxing district" means any unit of local
government, as defined in Section 1 of Article VII of the Constitution, with
the power to tax, and any school district or community college district.
(Source: P.A. 94-533, eff. 8-10-05.)
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(305 ILCS 5/6-1.8) (from Ch. 23, par. 6-1.8)
Sec. 6-1.8.
Multiple convictions for violations of this Code.
Any person
found guilty of a second violation of Article VIIIA shall be ineligible
for financial aid under this Article, as provided in Section 8A-8.
(Source: P.A. 82-440.)
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(305 ILCS 5/6-1.9) (from Ch. 23, par. 6-1.9)
Sec. 6-1.9.
An adult is eligible for aid under this Article if he is
(1) age 21 or over, (2) married and living with a spouse, regardless of
age, even if living in the residence of a natural or adoptive parent or
(3) age 18, 19, or 20 and not living with a natural or adoptive parent.
(Source: P.A. 83-1476.)
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(305 ILCS 5/6-1.10) (from Ch. 23, par. 6-1.10)
Sec. 6-1.10.
(Repealed).
(Source: Repealed by P.A. 88-554, eff. 7-26-94.)
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(305 ILCS 5/6-2) (from Ch. 23, par. 6-2)
Sec. 6-2. Amount of aid. The amount and nature of General Assistance
for basic maintenance requirements shall be determined in accordance
with local budget standards for local governmental units which do not receive
State funds. For local governmental units which do receive State funds,
the amount and nature of General Assistance for basic maintenance requirements
shall be determined in accordance with the standards, rules and regulations
of the Illinois Department. However,
the amount and nature of any
financial aid is not affected by the payment of any grant under the
Senior Citizens and Persons with Disabilities Property Tax Relief Act, any rebate authorized under Section 2201(a) of the Coronavirus Aid, Relief, and Economic Security Act (Public Law 116-136) or under any other federal economic stimulus program created in response to the COVID-19 emergency,
or any distributions or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act. Due regard shall be given to the
requirements and the conditions existing in each case, and to the income,
money contributions and other support and resources available, from
whatever source. In local governmental units which do not receive State
funds, the grant shall be sufficient when added to all other income, money
contributions and support in excess of any excluded income or resources, to
provide the person with a grant in the amount established for such a person
by the local governmental unit based upon standards meeting basic
maintenance requirements. In local governmental units which
do receive State funds, the grant shall be sufficient when added to all
other income, money contributions and support in excess of any excluded
income or resources, to provide the person with a grant in the amount
established for such a person by Department regulation based upon standards
providing a livelihood compatible with health and well-being, as directed
by Section 12-4.11 of this Code.
The Illinois Department may conduct special projects, which may be
known as Grant Diversion Projects, under which recipients of financial aid
under this Article are placed in jobs and their grants are diverted to the
employer who in turn makes payments to the recipients in the form of salary
or other employment benefits. The Illinois Department shall by rule specify
the terms and conditions of such Grant Diversion Projects. Such projects
shall take into consideration and be coordinated with the programs
administered under the Illinois Emergency Employment Development Act.
The allowances provided under Article IX for recipients participating in
the training and rehabilitation programs shall be in addition to such
maximum payment.
Payments may also be made to provide persons receiving basic
maintenance support with necessary treatment, care and supplies required
because of illness or disability or with acute medical treatment, care,
and supplies.
Payments for necessary or acute medical
care under
this paragraph may be made to or in behalf of the person. Obligations
incurred for such services but not paid for at the time of a recipient's
death may be paid, subject to the rules and regulations of the Illinois
Department, after the death of the recipient.
(Source: P.A. 101-632, eff. 6-5-20.)
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(305 ILCS 5/6-2.1) (from Ch. 23, par. 6-2.1)
Sec. 6-2.1.
Assets of homeless persons.
(a) For the purpose of assisting homeless persons in securing housing,
all assistance units that include a homeless person shall have an asset
disregard no less than that applicable to recipients of benefits under
Article 4 of this Code. For purposes of this Section, "homeless" or
"homeless person" means either of the following:
(1) An individual who lacks a fixed, regular, and | ||
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(2) An individual who has a primary nighttime | ||
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(A) A supervised publicly or privately operated | ||
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(B) An institution that provides a temporary | ||
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(C) A public or private place not designed for, | ||
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(b) While the Illinois Department shall consider other indicia of
homelessness in determining whether a person is homeless, a letter from a
shelter provider stating that a person is homeless or residing in its
shelter shall create a rebuttable presumption that the person is homeless.
(Source: P.A. 87-1185.)
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(305 ILCS 5/6-3) (from Ch. 23, par. 6-3)
Sec. 6-3.
Entitlement to social services.
Persons qualified for aid hereunder shall be entitled to receive, under
Article IX, such rehabilitative, training or other social services as are
appropriate to their condition.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/6-4) (from Ch. 23, par. 6-4)
Sec. 6-4.
(Repealed).
(Source: P.A. 85-1209. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/6-5) (from Ch. 23, par. 6-5)
Sec. 6-5.
Medical practitioners.
In supplying persons receiving basic maintenance support with necessary
treatment, care, and supplies required because of illness or
disability or with acute medical treatment, care, and supplies a local
governmental unit may provide for the services of persons
designated in Section 5-8 of Article V.
(Source: P.A. 89-646, eff. 1-1-97.)
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(305 ILCS 5/6-6) (from Ch. 23, par. 6-6)
Sec. 6-6.
Funeral and Burial.
If the estate of a deceased recipient is insufficient to pay for funeral
and burial expenses and if no other resources including assistance from
legally responsible relatives or the United States Veterans Administration,
are available for such purposes, there shall be paid, in accordance with
the standards, rules and regulations of the Illinois Department, such
amounts as may be necessary to meet costs of the funeral, burial space, and
cemetery charges, or to reimburse any person not financially responsible
for the deceased who has voluntarily made expenditures for such costs.
(Source: P.A. 90-372, eff. 7-1-98.)
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(305 ILCS 5/6-7) (from Ch. 23, par. 6-7)
Sec. 6-7.
Exemption for Townships.
Nothing in this Article shall be construed
as requiring townships to provide, in whole or in part, medical assistance
to persons who are not residents of the State of Illinois.
In all instances under this Article where medical aid or assistance to
a person who is not a resident of this State would otherwise be, in whole
or in part, the responsibility of a township, the Illinois Department shall
be responsible for such provision.
The Illinois Department shall, by rule or regulation, insure that provision
of such aid or assistance to a non-resident is identical to the uniform
standard of eligibility established by the Illinois Department.
(Source: P.A. 81-519.)
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(305 ILCS 5/6-8) (from Ch. 23, par. 6-8)
Sec. 6-8.
(Repealed).
(Source: P.A. 89-21, eff. 7-1-95. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/6-9) (from Ch. 23, par. 6-9) Sec. 6-9. (a)(1) A local governmental unit may provide assistance to households under its General Assistance program following a declaration by the President of the United States of a major disaster or emergency pursuant to the Federal Disaster Relief Act of 1974, as now or hereafter amended, if the local governmental unit is within the area designated under the declaration. A local governmental unit may also provide assistance to households under its General Assistance program following a disaster proclamation issued by the Governor if the local governmental unit is within the area designated under the proclamation. Assistance under this Section may be provided to households which have suffered damage, loss, or hardships as a result of the major disaster or emergency. Assistance under this Section may be provided to households without regard to the eligibility requirements and other requirements of this Code. Assistance under this Section may be provided only during the 90-day period following the date of declaration of a major disaster or emergency. (2) A local governmental unit shall not use State funds to provide assistance under this Section. If a local governmental unit receives State funds to provide General Assistance under this Article, assistance provided by the local governmental unit under this Section shall not be considered in determining whether a local governmental unit has qualified to receive State funds under Article XII. A local governmental unit which provides assistance under this Section shall not, as a result of payment of such assistance, change the nature or amount of assistance provided to any other individual or family under this Article. (3) This Section shall not apply to any municipality of more than 500,000 population in which a separate program has been established by the Illinois Department under Section 6-1. (b)(1) A local governmental unit may provide assistance to households for food and temporary shelter. To qualify for assistance a household shall submit to the local governmental unit: (A) such application as the local governmental unit may require; (B) a copy of an application to the Federal Emergency Management Agency (hereinafter "FEMA") or the Small Business Administration (hereinafter "SBA") for assistance; (C) such other proof of damage, loss, or hardship as the local governmental unit may require; and (D) an agreement to reimburse the local governmental unit for the amount of any assistance received by the household under this subsection (b). (2) Assistance under this subsection (b) may be in the form of cash or vouchers. The amount of assistance provided to a household in any month under this subsection (b) shall not exceed the maximum amount payable under Section 6-2. (3) No assistance shall be provided to a household after it receives a determination of its application to FEMA or SBA for assistance. (4) A household which has received assistance under this subsection (b) shall reimburse the local governmental unit in full for any assistance received under this subsection. If the household receives assistance from FEMA or SBA in the form of loans or grants, the household shall reimburse the local governmental unit from those funds. If the household's request for assistance is denied or rejected by the FEMA or SBA, the household shall repay the local governmental unit in accordance with a repayment schedule prescribed by the local governmental unit. (c)(1) A local governmental unit may provide assistance to households for structural repairs to homes or for repair or replacement of home electrical or heating systems, bedding, and food refrigeration equipment. To qualify for assistance a household shall submit to the local governmental unit: (A) such application as the local governmental unit may require; (B) a copy of claim to an insurance company for reimbursement for the damage or loss for which assistance is sought; (C) such other proof of damage, loss, or hardship as the local governmental unit may require; and (D) an agreement to reimburse the local governmental unit for the amount of any assistance received by the household under this subsection (c). (2) Any assistance provided under this subsection (c) shall be in the form of direct payments to vendors, and shall not be made directly to a household. The total amount of assistance provided to a household under this subsection (c) shall not exceed $1,500. (3) No assistance shall be provided to a household after it receives a determination of its insurance claims. (4) A household which has received assistance under this subsection (c) shall reimburse the local governmental unit in full for any assistance received under this subsection. If the household's insurance claim is approved, the household shall reimburse the local governmental unit from the proceeds. If the household's insurance claim is denied, the household shall repay the local governmental unit in accordance with a repayment schedule prescribed by the local governmental unit.(Source: P.A. 103-192, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/6-10) (from Ch. 23, par. 6-10)
Sec. 6-10. Emergency financial assistance. Except in a city, village or
incorporated town of more than 500,000 population, when an applicant
resides in the local governmental unit in which he makes application,
emergency financial assistance to alleviate life-threatening circumstances
or to assist the individual in attaining self-sufficiency may be given to
or in behalf of the applicant. The emergency assistance so given shall be
by vendor payment in an amount necessary to meet the need, up to the maximum
established by the local governmental unit. Emergency assistance
shall not be granted under this Section more than once to any applicant
during any 12 consecutive month period. Persons currently receiving
financial assistance
under this Article or under any other Article of this Code shall not be eligible
for emergency financial assistance under this Section. However, the amount and nature of any emergency financial assistance is not affected by the payment of any rebate authorized under Section 2201(a) of the Coronavirus Aid, Relief, and Economic Security Act (Public Law 116-136) or under any other federal economic stimulus program created in response to the COVID-19 emergency. Persons receiving
only medical assistance from the Illinois Department may, however, receive
emergency financial assistance under this Section. Emergency
financial assistance may be provided under this Section to persons who are
applicants for public aid from the Illinois Department in order to cover
time periods prior to receipt of public aid from the Illinois Department.
A local governmental unit may use General Assistance moneys to provide
emergency financial assistance under this Section but shall not use State
funds
to provide assistance
under this Section. If a local governmental unit receives State funds to
provide General Assistance under this Article, assistance provided by the
local governmental unit under
this Section shall not be considered in determining whether a local
governmental unit has qualified to receive State funds under Article XII.
A local governmental unit which provides assistance under this Section
shall not, as a result of payment of such assistance, change the nature or
amount of assistance provided to any other individual or family under this
Article.
(Source: P.A. 101-632, eff. 6-5-20.)
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(305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
Sec. 6-11. General Assistance.
(a) Effective July 1, 1992, all State funded General Assistance and related
medical benefits shall be governed by this Section, provided that, notwithstanding any other provisions of this Code to the contrary, on and after July 1, 2012, the State shall not fund the programs outlined in this Section. Other parts of this Code
or other laws related to General Assistance shall remain in effect to the
extent they do not conflict with the provisions of this Section. If any other
part of this Code or other laws of this State conflict with the provisions of
this Section, the provisions of this Section shall control.
(b) General Assistance may consist of 2 separate
programs. One program shall be for adults with no children and shall be
known as Transitional Assistance. The other program may be for
families with children and for pregnant women and shall be known as
Family and Children Assistance.
(c) (1) To be eligible for Transitional Assistance on or after July
1, 1992, an individual must be ineligible for assistance under any other
Article of this Code, must be determined chronically needy, and must be one of
the following:
(A) age 18 or over or
(B) married and living with a spouse, regardless of | ||
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(2) The local governmental unit shall determine
whether individuals are chronically needy as follows:
(A) Individuals who have applied for Supplemental | ||
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(B) (Blank).
(C) The unit of local government may specify other | ||
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(3) For individuals in Transitional Assistance, medical assistance may
be provided by the unit of local government in an amount and nature determined by the unit of local government. Nothing in this paragraph (3) shall be construed to require the coverage of
any particular medical service. In addition, the amount and nature of medical
assistance provided may be different for different categories of individuals
determined chronically needy.
(4) (Blank).
(5) (Blank).
(d) (1) To be eligible for Family and Children Assistance, a
family unit must be ineligible for assistance under any other Article of
this Code and must contain a child who is:
(A) under age 18 or
(B) age 18 and a full-time student in a secondary | ||
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Those children shall be eligible for Family and Children Assistance.
(2) The natural or adoptive parents of the child living in the same
household may be eligible for Family and Children Assistance.
(3) A pregnant woman whose pregnancy has been verified shall be
eligible for income maintenance assistance under the Family and
Children Assistance program.
(4) The amount and nature of medical assistance provided under the
Family and Children Assistance program shall be determined by the unit of local government. The amount and nature of medical
assistance provided
need not be the same as that provided under paragraph (3) of
subsection (c) of this Section, and nothing in this paragraph (4) shall be
construed to require the coverage of any particular medical service.
(5) (Blank).
(e) A local governmental unit that chooses to participate in a
General Assistance program under this Section shall provide
funding in accordance with Section 12-21.13 of this Act.
Local governmental funds used to qualify for State funding may only be
expended for clients eligible for assistance under this Section 6-11 and
related administrative expenses.
(f) (Blank).
(g) (Blank).
(Source: P.A. 99-143, eff. 7-27-15; 100-759, eff. 1-1-19.)
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(305 ILCS 5/6-11a) Sec. 6-11a. Townships. A local governmental unit may provide assistance under its General Assistance program under a service that complies with Section 85-13 of the Township Code. Before a local governmental unit provides assistance under this Section, the board of the local governmental unit shall adopt a policy providing which services are eligible under Section 85-13 of the Township Code for General Assistance.(Source: P.A. 103-192, eff. 1-1-24.) |
(305 ILCS 5/6-12) (from Ch. 23, par. 6-12) Sec. 6-12. General Assistance not funded by State. General Assistance programs in local governments that do not receive State funds shall continue to be governed by Sections 6-1 through 6-10, as applicable, as well as other relevant parts of this Code and other laws. However, notwithstanding any other provision of this Code, any unit of local government that does not receive State funds may implement a General Assistance program that complies with Sections 6-11 and 6-11a. So long as the program complies with either Section 6-11 or 6-12, the program shall not be deemed out of compliance with or in violation of this Code.(Source: P.A. 103-192, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/Art. VIIIA heading) ARTICLE VIIIA.
PUBLIC ASSISTANCE FRAUD
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(305 ILCS 5/8A-1) (from Ch. 23, par. 8A-1)
Sec. 8A-1.
Legislative Intent.
Because of the pervasive nature of public
assistance fraud and its negative effect on the people of the State of Illinois
and those individuals who need public assistance, the General Assembly declares
it to be public policy that public assistance fraud be identified and dealt
with swiftly and appropriately considering the onerous nature of the crime.
(Source: P.A. 82-440.)
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(305 ILCS 5/8A-2) (from Ch. 23, par. 8A-2)
Sec. 8A-2. Recipient Fraud. (a) Any person, who by means of any false
statement, willful misrepresentation or failure to notify the county department
or the local governmental unit, as the case may be, of a change in his status
as required by Sections 11-18 and 11-19, or any person who knowingly causes
any applicant or recipient without knowledge to make such a false statement
or willful misrepresentation, or by withholding information causes the applicant
or recipient to fail to notify the county department or local governmental
unit as required, for the purpose of preventing the denial, cancellation
or suspension of any grant, or a variation in the amount thereof, or through
other fraudulent device obtains or attempts to obtain, or aids or abets
any person in obtaining public aid under this Code to which he is not entitled
is guilty of a violation of this Article and shall be punished as provided
in Section 8A-6.
(b) If an applicant makes and subscribes an application form under Section
11-15 which contains a written declaration that it is made under penalties
of perjury, knowing it to be false, incorrect or incomplete in respect
to any material statement or representation bearing on his eligibility,
income or resources, the offender shall be subject to the penalties for
perjury as provided in Section 32-2 of the Criminal Code of 2012.
(Source: P.A. 97-1150, eff. 1-25-13.)
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(305 ILCS 5/8A-2.5)
Sec. 8A-2.5. Unauthorized use of medical assistance.
(a) Any person who knowingly uses, acquires, possesses, or transfers a
medical card in any manner not authorized by law or by rules and regulations of
the Illinois Department, or who knowingly alters a medical card, or who
knowingly uses, acquires, possesses, or transfers an altered medical card, is
guilty of a violation of this Article and shall be punished as provided in
Section 8A-6.
(b) Any person who knowingly obtains unauthorized medical benefits or causes to be obtained unauthorized medical benefits with or
without use of a medical card is guilty of a violation of this Article and
shall be punished as provided in Section 8A-6.
(b-5) Any vendor that knowingly assists a person in committing a violation under subsection (a) or (b) of this Section is guilty of a violation of this Article and shall be punished as provided in Section 8A-6. (b-6) Any person (including a vendor, organization, agency, or other entity) that, in any matter related to the medical assistance program, knowingly or willfully falsifies, conceals, or omits by any trick, scheme, artifice, or device a material fact, or makes any false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with the provision of health care or related services, is guilty of a violation of this Article and shall be punished as provided in Section 8A-6. (c) The Department may seek to recover any and all State and federal monies for which it has improperly and erroneously paid benefits as a result of a fraudulent action and any civil penalties authorized in this Section. Pursuant to Section 11-14.5 of this Code, the Department may determine the monetary value of benefits improperly and erroneously received. The Department may recover the monies paid for such benefits and interest on that amount at the rate of 5% per annum for the period from which payment was made to the date upon which repayment is made to the State. Prior to the recovery of any amount paid for benefits allegedly obtained by fraudulent means, the recipient or payee of such benefits shall be afforded an opportunity for a hearing after reasonable notice. The notice shall be served personally or by certified or registered mail or as otherwise provided by law upon the parties or their agents appointed to receive service of process and shall include the following: (1) A statement of the time, place and nature of the | ||
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(2) A statement of the legal authority and | ||
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(3) A reference to the particular Sections of the | ||
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(4) Except where a more detailed statement is | ||
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(5) A statement of the monetary value of the benefits | ||
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(6) A statement that, in addition to any other | ||
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(7) A statement providing that the determination of | ||
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(8) The names and mailing addresses of the | ||
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An opportunity shall be afforded all parties to be represented by legal counsel and to respond and present evidence and argument. Unless precluded by law, disposition may be made of any contested case by stipulation, agreed settlement, consent order, or default. Any final order, decision, or other determination made, issued or executed by the Director under the provisions of this Article whereby any person is aggrieved shall be subject to review in accordance with the provisions of the Administrative Review Law, and the rules adopted pursuant thereto, which shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Director. Upon entry of a final administrative decision for repayment of any benefits obtained by fraudulent means, or for any civil penalties assessed, a lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution, vendor, or other legal entity until the judgment is satisfied. Within 18 months of the effective date of this amendatory Act of the 96th General Assembly, the Department of Healthcare and Family Services will report to the General Assembly on the number of fraud cases identified and pursued, and the fines assessed and collected. The report will also include the Department's analysis as to the use of private sector resources to bring action, investigate, and collect monies owed. (d) In subsections (a), (b), (b-5) and (b-6), "knowledge" has the meaning ascribed to that term in Section 4-5 of the Criminal Code of 2012. For any administrative action brought under subsection (c) pursuant to a violation of this Section, the Department shall define "knowing" by rule. (Source: P.A. 97-23, eff. 1-1-12; 98-354, eff. 8-16-13.)
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(305 ILCS 5/8A-3) (from Ch. 23, par. 8A-3)
Sec. 8A-3.
Vendor Fraud and Kickbacks.
(a) Any person, firm, corporation,
association, agency, institution or other legal entity that willfully, by
means of a false statement or representation, or by concealment of any material
fact or by other fraudulent scheme or device on behalf of himself or others,
obtains or attempts to obtain benefits or payments under this Code to which
he or it is not entitled, or in a greater amount than that to which he or
it is entitled, is guilty of a violation of this Article and shall be punished
as provided in Section 8A-6.
(b) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he solicits or receives any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind:
(1) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or service for which
payment may be made in whole or in part under this Code; or
(2) in return for purchasing, leasing, ordering, or arranging for or
recommending purchasing, leasing, or ordering any good, facility, service
or item for which payment may be made in whole or in part under this Code.
(c) A person shall be guilty of a violation of this Article and shall
be punished as provided in Section 8A-6 if he offers or pays any
remuneration, including any kickback,
bribe, or rebate, directly or indirectly, overtly or covertly, in cash or
in kind to any person to induce such person:
(1) to refer an individual to a person for the furnishing or arranging
for the furnishing of any item or service for which payment may be made in
whole or in part under this Code; or
(2) to purchase, lease, order, or arrange for or recommend purchasing,
leasing, or ordering any good, facility, service, or item for which payment
may be made in whole or in part under this Code.
(d) Subsections (b) and (c) shall not apply to:
(1) a discount or other reduction in price obtained by a provider of
services or other entity under this Code if the reduction in price is
properly disclosed and appropriately reflected in the costs claimed or
charges made by the provider or entity under this Code;
(2) any amount paid by an employer to an employee who has a bona fide
employment relationship with such employer for employment in the provision
of covered items or services; or
(3) any amount
paid to or received by a physician for professional
services rendered if a physician, pursuant to a bona fide contract with
a health maintenance organization, as defined by the Health
Maintenance Organization Act, has referred a patient to another physician
for rendering professional services not covered by the health maintenance
organization.
(Source: P.A. 85-818.)
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(305 ILCS 5/8A-3.5) Sec. 8A-3.5. Vendor fraud and recipient fraud in medical assistance; restitution. A person convicted of recipient fraud, unauthorized use of medical assistance, vendor fraud in relation to the provision of medical assistance under Article V of this Code, or convicted of a federal criminal violation associated with defrauding the Medicaid program shall be ordered to pay
monetary
restitution to a person for any
financial loss
sustained by that person as a result of a violation of Section 8A-2, 8A-2.5, or 8A-3 of this Code, including any court costs
and attorney
fees. An order of restitution also includes expenses incurred and paid
in connection with any medical evaluation or treatment.
(Source: P.A. 94-577, eff. 1-1-06.) |
(305 ILCS 5/8A-3.6) Sec. 8A-3.6. Actions by State licensing agencies.
(a) All State licensing agencies, the Illinois State Police, and
the
Department of Financial and Professional Regulation shall coordinate enforcement efforts relating to acts
of recipient fraud, unauthorized use of medical assistance, or vendor fraud in relation to the provision of medical assistance under Article V of this Code. (b) If a person who is licensed or registered under the laws of the State of
Illinois to engage in a business or profession is convicted of or pleads
guilty to engaging
in an act of recipient fraud, unauthorized use of medical assistance, or vendor fraud in relation to the provision of medical assistance under Article V of this Code, the Illinois State Police must forward
to each
State agency by which the person is licensed or registered a copy of the
conviction or
plea and all supporting evidence. (c) Any agency that receives information under this Section shall, not later
than
6 months after the date on which it receives the information, publicly report the final action
taken
against the convicted person, including but not limited to the revocation or
suspension
of the license or any other disciplinary action taken.
(Source: P.A. 94-577, eff. 1-1-06.) |
(305 ILCS 5/8A-4) (from Ch. 23, par. 8A-4)
Sec. 8A-4.
Penalty for Unauthorized Use of Federal Food Stamps or Federal
Food Stamp Benefits. Any
person who knowingly uses, acquires, possesses, or transfers
federal food
stamps, or federal food stamp benefits, or Electronic Benefit Transfer card
for federal food stamp benefits, or authorizations to participate in the
federal food stamp program
in any manner not authorized by law or the rules and regulations of the
Illinois Department, or who knowingly alters or uses, acquires, possesses
or transfers altered federal food stamps,
or federal food stamp benefits, or
Electronic Benefit Transfer card for federal food stamp benefits,
or authorizations to participate in the federal food stamp program,
or who
knowingly alters or falsifies electronic federal food stamp benefit data or
possesses or uses altered or falsified electronic federal food stamp benefit
data for the purpose of making claims for or receiving redemption of food stamp
benefits or for the substantiation of redemptions received,
is guilty of a violation of this Article
and shall be punished as provided in Section 8A-6.
(Source: P.A. 89-489, eff. 1-1-97.)
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(305 ILCS 5/8A-4A) (from Ch. 23, par. 8A-4A)
Sec. 8A-4A.
Penalty for Unauthorized Use of Federal Surplus
Commodities. Any person who knowingly uses, acquires, possesses, or
transfers federal surplus food commodities or authorizations to participate
in the federal surplus food commodities program, in original or altered form, in
any manner not authorized by law or the rules and regulations of the
Illinois Department, or who knowingly alters authorizations to participate
in the federal surplus food commodities program, is guilty of a violation of
this Article and shall be punished as provided in Section 8A-6.
(Source: P.A. 85-555.)
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(305 ILCS 5/8A-5) (from Ch. 23, par. 8A-5)
Sec. 8A-5.
Administrative Malfeasance.
(a) Any person who shall misappropriate,
misuse or unlawfully withhold or convert to his own use or to the use of
another, any public funds made available for public aid purposes under this
Code is guilty of a violation of this Article and shall be punished as provided
in Section 8A-6.
(b) Any official or employee of the Illinois Department, county department
or local governmental unit who willfully fails to report a known violation
of Sections 8A-2, 8A-3, 8A-4 or 8A-5 to the designated administrative personnel
as identified in the policy and procedures of the Illinois Department for
employees of the Illinois Department or county department, or to the State's
Attorney for employees of a local governmental unit, shall be subject to
disciplinary proceedings pursuant to regulations of the Illinois Department
or local governmental unit.
(Source: P.A. 82-440.)
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(305 ILCS 5/8A-5A) (from Ch. 23, par. 8A-5A)
Sec. 8A-5A.
Unauthorized possession of identification document.
Any
person who possesses for an unlawful purpose another person's
identification document issued by the Illinois Department shall be guilty
of a Class 4 felony. For purposes of this Section, "identification
document" includes but is not limited to an authorization to participate in
the federal food stamp program or the federal surplus food commodities
program, or a card or other document which identifies a person as being
entitled to public aid under this Code.
(Source: P.A. 86-1012.)
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(305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)
Sec. 8A-6.
Classification of violations.
(a) Any person, firm, corporation,
association, agency, institution or other legal entity that has been found
by a court to have engaged in an act, practice or course of conduct declared
unlawful under Sections 8A-2 through 8A-5 or Section 8A-13 or 8A-14 where:
(1) the total amount of money involved in the | ||
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(2) the total amount of money involved in the | ||
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(3) the total amount of money involved in the | ||
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(4) the total amount of money involved in the | ||
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(5) the total amount of money involved in the | ||
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(b) Any person, firm, corporation, association, agency, institution
or other legal entity that commits a subsequent violation of any of the
provisions of Sections 8A-2 through 8A-5 and:
(1) the total amount of money involved in the | ||
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(2) the total amount of money involved in the | ||
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(3) the total amount of money involved in the | ||
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(4) the total amount of money involved in the | ||
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(c) For purposes of determining the classification of offense under
this Section, all of the money received as a result of the unlawful act,
practice or course of conduct can be accumulated.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-7) (from Ch. 23, par. 8A-7) Sec. 8A-7. Civil remedies. (a) A person who receives financial aid by means of a false statement, willful misrepresentation or by his failure to notify the county department or local governmental unit, as the case may be, of a change in his status as required by Sections 11-18 and 11-19, for the purpose of preventing the denial, cancellation or suspension of his grant, or a variation in the amount thereof, or by other fraudulent device, or a person who knowingly aids or abets any person in obtaining financial aid for which he is not eligible, shall be answerable to the county department or the local governmental unit, as the case may be, for refunding the entire amount of aid received. If the refund is not made, it shall be recoverable in a civil action from the person who received the aid, or from anyone who willfully aided such person to obtain the aid. If an act which would be unlawful under Section 8A-2 is proven, the court may as a penalty assess an additional sum of money, not to exceed the entire amount of aid provided, against the recipient or against any person who willfully aided the recipient. If assessed, the penalty shall be included in any judgment entered for the aid received, and paid to the county department or the local governmental unit, as the case may be. Upon entry of the judgment a lien shall attach to all property and assets of such person until the judgment is satisfied. (b) Any person, firm, corporation, association, agency, institution or other legal entity, other than an individual recipient, that willfully, by means of a false statement or representation, or by concealment of any material fact or by other fraudulent scheme or device on behalf of himself or others, obtains or attempts to obtain benefits or payments under this Code to which he or it is not entitled, or in a greater amount than that to which he or it is entitled, shall be liable for repayment of any excess benefits or payments received and, in addition to any other penalties provided by law, civil penalties consisting of (1) the interest on the amount of excess benefits or payments at the maximum legal rate in effect on the date the payment was made to such person, firm, corporation, association, agency, institution or other legal entity for the period from the date upon which payment was made to the date upon which repayment is made to the State, (2) an amount not to exceed 3 times the amount of such excess benefits or payments, and (3) the sum of $2,000 for each excessive claim for benefits or payments. Upon entry of a judgment for repayment of any excess benefits or payments, or for any civil penalties assessed by the court, a lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution or other legal entity until the judgment is satisfied. (c) Civil recoveries provided for in this Section may be recoverable in court proceedings initiated by the Attorney General or, in actions involving a local governmental unit, by the State's Attorney. (d) Any person who commits the offense of vendor fraud or recipient fraud as defined in Section 8A-2 and Section 8A-3 of this Article shall forfeit, according to the provisions of this subsection, any monies, profits or proceeds, and any interest or property which the sentencing court determines he has acquired or maintained, directly or indirectly, in whole or in part as a result of such offense. Such person shall also forfeit any interest in, securities of, claim against, or contractual right of any kind which affords him a source of influence over, any enterprise which he has established, operated, controlled, conducted, or participated in conducting, where his relationship to or connection with any such thing or activity directly or indirectly, in whole or in part, is traceable to any thing or benefit which he has obtained or acquired through vendor fraud or recipient fraud. Proceedings instituted pursuant to this subsection shall be subject to and conducted in accordance with the following procedures: (1) The sentencing court shall, upon petition by the | ||
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(2) In any action brought by the People of the State | ||
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(3) Upon conviction of a person under this Article, | ||
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(4) The Director of the Illinois State Police is | ||
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(a) 25% shall be distributed to the unit of local | ||
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(b) 25% shall be distributed to the county in | ||
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(c) 50% shall be transmitted to the State | ||
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(Source: P.A. 102-538, eff. 8-20-21; 103-145, eff. 10-1-23.) |
(305 ILCS 5/8A-7.1) (from Ch. 23, par. 8A-7.1)
Sec. 8A-7.1. The Director, upon making a
determination based upon information in the possession of the Illinois
Department, that continuation in practice of a licensed health care
professional would constitute an immediate danger to the public, shall submit
a written communication to the Director of Professional Regulation indicating
such determination and
additionally providing a complete summary of the information upon which
such determination is based, and recommending that the Director of
Professional Regulation immediately suspend such person's
license. All relevant evidence, or copies thereof, in the Illinois
Department's possession may also be submitted in conjunction with the written
communication. A copy of such written communication, which is exempt from
the copying and inspection provisions of the Freedom of Information Act,
shall at the time of submittal to the Director
of Professional Regulation
be simultaneously mailed to the last known business address of such licensed
health care professional by certified or registered postage, United States
Mail, return receipt requested. Any evidence, or copies thereof, which is
submitted in conjunction with the written communication is also exempt from
the copying and inspection provisions of the Freedom of Information Act.
The Director, upon making a determination based upon information in the
possession of the Illinois Department, that a licensed health care
professional is willfully committing fraud upon the Illinois Department's
medical assistance program, shall submit a written communication to the
Director of Professional Regulation indicating such
determination and additionally providing a complete summary of the
information upon which such determination is based. All relevant evidence,
or copies thereof, in the Illinois Department's possession may also be
submitted in conjunction with the written communication.
Upon receipt of such written communication, the Director of
Professional Regulation shall promptly investigate the
allegations contained in such written communication. A copy of such
written communication, which is exempt from the copying and inspection
provisions of the Freedom of Information Act, shall at the time of
submission to the Director of Professional Regulation,
be simultaneously mailed to the last known address of such licensed health
care professional by certified or registered postage, United States Mail,
return receipt requested. Any evidence, or copies thereof, which
is submitted in conjunction with the written communication is also exempt
from the copying and inspection provisions of the Freedom of Information Act.
For the purposes of this Section, "licensed health care professional"
means any person licensed under the Illinois Dental Practice Act, the Nurse Practice Act, the Medical Practice Act of 1987, the
Pharmacy Practice Act, the Podiatric Medical Practice Act of 1987,
or the Illinois Optometric Practice Act of 1987.
(Source: P.A. 95-639, eff. 10-5-07; 95-689, eff. 10-29-07; 95-876, eff. 8-21-08.)
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(305 ILCS 5/8A-8) (from Ch. 23, par. 8A-8)
Sec. 8A-8.
Future Participation in the Public Assistance Program.
(a) Any person applying for public assistance under this Code who has been
found
guilty of a violation of this Article or of any law of the United States or
of any state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs of the kind provided under this Code and who has not been previously
convicted
for a violation of this Article or of any law of the United States or of any
state which is substantially similar to Sections 8A-2 through 8A-5
for violations related to public assistance or medical assistance
programs
of the kind provided under this Code shall have applications for public
assistance
under this Code reviewed by an administrative review board to determine
the person's eligibility and the need for administrative safeguards to prevent
any such further violations. The administrative review board shall be
composed of not less than two persons who are selected in accordance with
regulations of the Illinois Department or the local governmental unit. Hearings
conducted by the board shall:
(1) be of an informal nature, permitting the | ||
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(2) be open to the public, unless the applicant and | ||
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(3) be subject to reasonable time and notification | ||
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(4) be held at a location convenient to the applicant.
At the hearing, the administrative review board may deny the application
based on an investigation of the person's eligibility, or the board may
appoint a substitute payee, require more frequent visits or consultations,
more frequent financial reports or require any other action to the extent
permitted by State and federal law and regulations. A decision by the
administrative review board to deny a person's application shall only be
based on the person's failure to qualify under the eligibility criteria
applicable to all applicants for the public assistance program in question.
Any decision by the administrative review board may be appealed pursuant to
the provisions of this Code. In no instance shall the administrative review
board delay the hearing or its decision beyond the time allowed under State
or federal law and regulations for determining an applicant's eligibility
for public assistance.
If the person has been determined eligible, the Illinois Department or
the local governmental unit may recoup prior payments obtained in violation
of this Article from the current cash assistance grants, unless such payments
have previously been repaid. The Illinois Department or the local governmental
unit, on a case by case basis, shall limit the amount deducted from the current
cash assistance grant so as not to cause undue hardship to the person.
(b) To the extent permitted under federal law, any person found
guilty of a first violation of this Article or of any law of the United
States
or
of any state which is substantially similar to Sections 8A-2 through 8A-5 for
violations related to public assistance or medical assistance programs of the
kind provided under this Code may be suspended from eligibility for public
aid under this Code. Any person found guilty of a second or subsequent
violation of this Article or of any law of the United States or of any state
which is substantially similar to Sections 8A-2 through 8A-5 for violations
related to public assistance or medical assistance programs of the kind
provided under this Code shall be ineligible for public aid under this
Code.
(c) In no instance shall this Section adversely affect the eligibility
of children who are in need of public aid under this Code, or the amount
of the grant received by such children. If a child's caretaker relative
is adversely affected by this Section, a substitute payee may be appointed
until the Illinois Department can determine, by rule, that the caretaker
relative can manage the public aid in the best interest of the child.
(d) Any person, firm, corporation, association, agency, institution or
other legal entity that has been convicted of a violation of this Article
shall be prohibited from participating as a vendor of goods or services
to recipients of public aid under this Code. Such prohibition shall extend
to any person with management responsibility in a firm, corporation,
association, agency, institution, or other legal entity that has been
convicted of any such violation and to an officer or person owning, either
directly or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporation.
(e) Any employee of the Illinois Department, county department or local
governmental unit who has been found guilty of a violation of this Article
shall be terminated from employment.
(Source: P.A. 89-489, eff. 1-1-97; 90-725, eff. 8-7-98.)
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(305 ILCS 5/8A-9) (from Ch. 23, par. 8A-9)
Sec. 8A-9.
Special Investigations Unit.
There shall be established within
the administrative staff a unit to investigate all matters pertaining to
the fraudulent acquisition of public aid, including administrative funds.
The investigation may be conducted without prior notice to the recipients,
to the personnel administering the cases or to vendors or other persons involved.
The unit shall also investigate any other matter relating to the administration
of public aid assigned to it by the Director of the Illinois Department.
The Illinois Department may make the facts revealed by any investigation
available to the Attorney General or to the appropriate State's Attorney.
(Source: P.A. 82-440.)
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(305 ILCS 5/8A-10) (from Ch. 23, par. 8A-10)
Sec. 8A-10.
Savings provisions.
Notwithstanding any amendments or repealer
provisions in this amendatory Act of 1981, Sections 11-21, 11-24, 12-15,
12-15.1 and 12-21.19 of "The Illinois Public Aid Code" shall remain in force
(1) for the prosecution and punishment of any person who, before the effective
date of this amendatory Act, has violated Section 11-21, 11-24, 12-15.1
or 12-21.19 of this Code, and (2) for the initiation and enforcement
of civil actions and penalties for any cause of action which accrued prior
to the effective date of this amendatory Act under Section 11-21 or 12-15
of this Code.
This amendatory Act of 1981 shall apply only to causes of action arising
from violations of this Code which occur after its effective date.
(Source: P.A. 82-440.)
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(305 ILCS 5/8A-11) (from Ch. 23, par. 8A-11)
Sec. 8A-11. (a) No person shall:
(1) Knowingly charge a resident of a nursing home for | ||
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(2) Knowingly charge, solicit, accept or receive, in | ||
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(i) As a precondition to admitting or expediting | ||
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(ii) As a requirement for the recipient's or | ||
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(b) Nothing herein shall prohibit a person from making a voluntary
contribution, gift or donation to a long-term care facility.
(c) This paragraph shall not apply to agreements to provide continuing
care or life care between a life care facility as defined by the Life
Care Facilities Act, and a person financially eligible for benefits pursuant to
Article V of the Illinois Public Aid Code.
(d) Any person who violates this Section shall be guilty of a business
offense and fined not less than $5,000 nor more than $25,000.
(e) "Person", as used in this Section, means an individual, corporation,
partnership, or unincorporated association.
(f) The State's Attorney of the county in which the facility is located
and the Attorney General shall be notified by the Illinois Department of
any alleged violations of this Section known to the Department.
(g) The Illinois Department shall adopt rules and regulations to carry
out the provisions of this Section.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
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(305 ILCS 5/8A-12)
Sec. 8A-12.
Early fraud prevention and detection program.
The Illinois
Department may conduct an early fraud prevention and detection program as
provided in this Section. If conducted, the program shall apply to all
categories of assistance and all applicants for aid. The program may be
conducted in appropriate counties as determined by the Department. The
program shall have the following features:
(1) No intimidation of applicants or recipients may | ||
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(2) An applicant may not be referred for a fraud | ||
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(3) An applicant may be referred to the Inspector | ||
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(Source: P.A. 89-118, eff. 7-7-95.)
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(305 ILCS 5/8A-13)
Sec. 8A-13. Managed health care fraud.
(a) As used in this Section, "health plan" means any of the following:
(1) Any health care reimbursement plan sponsored | ||
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(2) Any private insurance carrier, health care | ||
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(3) Anyone who provides or contracts to provide goods | ||
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For purposes of item (2) in subsection (b), "representation" and "statement"
include, but are not limited to, reports, claims, certifications,
acknowledgments and ratifications of financial information, enrollment claims,
demographic statistics, encounter data, health services available or rendered,
and the qualifications of person rendering health care and ancillary services.
(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that, with the intent to obtain benefits or payments under
this Code to which the person or entity is not entitled or in a greater amount
than that to which the person or entity is entitled, knowingly or willfully:
(1) executes or conspires to execute a scheme or | ||
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(2) executes or conspires to execute a scheme or | ||
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(3) falsifies, conceals, or covers up by any trick, | ||
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(4) makes any materially false, fictitious, or | ||
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(5) makes or uses any false writing or document | ||
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is guilty of a
violation of this Article and shall be punished as provided in Section 8A-6.
(Source: P.A. 98-354, eff. 8-16-13.)
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(305 ILCS 5/8A-14)
Sec. 8A-14.
Bribery and graft in connection with health care.
(a) As used in this Section:
"Health care official" means any of the following:
(1) An administrator, officer, trustee, fiduciary, | ||
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(2) An officer, counsel, agent, or employee of an | ||
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(3) An official, employee, or agent of a State or | ||
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"Health plan" has the meaning attributed to that term in Section 8A-13.
(b) Any person, firm, corporation, association, agency, institution, or
other legal entity that
(1) directly or indirectly gives, offers, or promises | ||
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(A) to influence or reward any act or decision of | ||
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(B) to influence the official to commit, aid in | ||
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(C) to induce the official to engage in any | ||
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(2) being a health care official, directly or | ||
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is guilty of a violation of this Article and shall be punished as
provided in Section 8A-6.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-15)
Sec. 8A-15. False statements relating to health care delivery. Any
person, firm, corporation, association, agency, institution, or other legal
entity that, in any matter related to a State or federally funded or mandated
health plan, knowingly and wilfully falsifies, conceals, or omits by any trick,
scheme, artifice, or device a material fact, or makes any false, fictitious, or
fraudulent statement or representation, or makes or uses any false writing or
document, knowing the same to contain any false, fictitious, or fraudulent
statement or entry in connection with the provision of health care or related
services, is guilty of a Class 4 felony.
(Source: P.A. 98-354, eff. 8-16-13.)
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(305 ILCS 5/8A-16)
Sec. 8A-16.
Unfair or deceptive marketing practices.
(a) As used in this Section, "health plan" has the meaning attributed to
that term in Section 8A-13.
(b) It is unlawful to knowingly and willfully engage in any unfair or
deceptive marketing practice
in connection with proposing, offering, selling, soliciting, or providing any
health care service or any health plan. Unfair or deceptive marketing
practices include the following:
(1) Making a false and misleading oral or written | ||
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(2) Making a representation that a health care plan | ||
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(3) Making a representation that a health plan or | ||
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(4) A failure to state a material fact if the failure | ||
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(5) Offering any kickback, bribe, reward, or benefit | ||
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(6) The use of health care consumer or other | ||
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(A) medical records information; and
(B) information that identifies the health care | ||
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(7) The use of any device or artifice in advertising | ||
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(c) Any person who commits a first violation of this Section is guilty of a
Class
A misdemeanor and is subject to a fine of not more than $5,000. Any person who
commits a second or subsequent violation of this Section is guilty of a Class 4
felony and is subject to a fine of not more than $25,000.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-17)
Sec. 8A-17.
Penalties enhanced for persons other than individuals.
If a
person who violates Section 8A-13, 8A-14, 8A-15, or 8A-16 is any person other
than an individual, then that person is subject to a fine of not more than
$50,000 if the violation is a misdemeanor and a fine of not more than $250,000
if the violation is a felony.
(Source: P.A. 90-538, eff. 12-1-97.)
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(305 ILCS 5/8A-18) Sec. 8A-18. Application assistance fraud; SNAP; AABD; TANF. It is a Class C misdemeanor for any person, including an individual, firm, corporation, association, partnership, or joint venture, or any employee or agent of any of those, to assist or represent another person in completing or submitting an application for benefits under the federal Supplemental Nutrition Assistance Program (SNAP), the State's Aid to the Aged, Blind, or Disabled (AABD) program, or the State's Temporary Assistance for Needy Families (TANF) program, in exchange for a portion of the applicant's SNAP, AABD, or TANF benefits or cash or any other form of payment from any other source. An applicant who receives such assistance or representation is not in violation of this Section. Nothing in this Section shall be construed as prohibiting an applicant from receiving such assistance or representation when appealing a denial of an application for SNAP, AABD, or TANF benefits.
(Source: P.A. 98-931, eff. 8-15-14.) |
(305 ILCS 5/Art. IX heading) ARTICLE IX.
OTHER SOCIAL SERVICES
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(305 ILCS 5/9-1) (from Ch. 23, par. 9-1)
Sec. 9-1. Declaration of Purpose. It is the purpose
of this Article to aid applicants for and
recipients of public aid under Articles III, IV, V, and VI, to
increase their capacities for self-support, self-care, and responsible
citizenship, and to assist them in maintaining and strengthening family
life. If authorized pursuant to Section 9-8, this Article may be
extended to former and potential recipients and to persons whose income
does not exceed the standard established to determine eligibility for
aid as a medically indigent person under Article V. The Department, with
the written consent of the Governor, may also:
(a) extend this Article to individuals and their | ||
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(b) establish, where indicated, schedules of payment | ||
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(c) provide for the coordinated delivery of the | ||
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(d) provide in-home care services, such as chore and | ||
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(e) contract with other State agencies for the | ||
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(f) cooperate with the Department of Healthcare and | ||
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(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/9-2) (from Ch. 23, par. 9-2)
Sec. 9-2.
Guidance and Counseling Services.
Guidance and counseling services shall be provided directly by the
staffs of the Illinois Department, the County Departments, and local
governmental units, or through cooperating governmental and private
agencies which will assist in preventing or overcoming financial
dependency or social maladjustment; in maintaining and strengthening family
life; in assisting parents who are unmarried, divorced or separated to share
in the support and maintenance of their children; in increasing the capacities of
parents or other adults for
attaining or maintaining a decent and healthful standard of living for
themselves and any children they may have under their care; and in
encouraging and aiding parents or other adults to provide children under
their care with maximum opportunities for realizing their full
potentialities for development.
In local governmental units receiving State funds, the establishment
of such services and the expenditure of funds therefor shall be subject
to the approval and supervision of the Illinois Department.
(Source: P.A. 81-968.)
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(305 ILCS 5/9-3) (from Ch. 23, par. 9-3)
Sec. 9-3.
Rehabilitative Services.
The Illinois Department, the County Departments, and local governmental
units shall encourage and assist applicants and recipients to make maximum
use of the facilities of public or private agencies providing
rehabilitative services for persons afflicted with physical, mental or
social disabilities requiring specialized care and treatment.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/9-4)
Sec. 9-4. (Repealed).
(Source: P.A. 86-1381. Repealed by P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/9-5) (from Ch. 23, par. 9-5)
Sec. 9-5.
Educational programs; vocational training and retraining.
The Illinois Department, the County Departments, and local governmental
units shall cooperate with all public or private education and
vocational training or retraining agencies or facilities operating
within this State, or making their services available to residents of
this State, to the end that there may be developed all necessary
education and vocational training or retraining services and facilities
required to improve the skills of persons receiving aid under Articles
III, V, and VI for whom jobs are not immediately available, or
which will provide education, training, and experience for persons who
lack the skills required for employment opportunities as are or may
become available. The education, training, or retraining services and
facilities shall assure that persons receiving this
assistance who are subject to participation shall become enrolled in, and
attend, programs that will lead to graduation from high school or the
equivalent when the Illinois Department determines these
programs will be beneficial to the person in obtaining employment.
Participants in any educational or vocational training
program shall be provided with an extra allowance towards the costs of
their participation.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6) (from Ch. 23, par. 9-6)
Sec. 9-6.
Job Search, Training and Work Programs.
The Illinois Department
and local governmental units shall initiate, promote and develop job search,
training and work programs which will provide employment for and contribute
to the training and experience of persons receiving aid under Articles III,
V, and VI.
The job search, training and work programs shall be designed to preserve and
improve the work habits and skills of recipients for whom jobs are not
otherwise immediately available and to provide training and experience for
recipients who lack the skills required for such employment opportunities as
are or may become available. The Illinois Department and local governmental
unit shall determine by rule those classes of recipients who shall be subject
to participation in such programs. If made subject to participation, every
applicant for or recipient of public aid who is determined to be "able to
engage in employment", as defined by the Department or local governmental unit
pursuant to rules and regulations, for whom unsubsidized jobs are not otherwise
immediately available shall be required to participate in any program
established under this Section.
The Illinois Department shall establish with the Director of Central
Management Services an outreach and training
program designed to encourage and assist recipients participating in job
search, training and work programs to participate in open competitive
examinations for trainee and other entry level positions to maximize
opportunities for placement on open competitive eligible listings and
referral to State agencies for employment consideration.
The Department shall provide payment for transportation, day-care and
Workers' Compensation costs which occur for recipients as a result of
participating in job search, training and work programs as described in
this Section. The Department may decline to initiate such programs in
areas where eligible recipients would be so few in number as to not
economically justify such programs; and in this event the Department shall
not require persons in such areas to participate in any job search,
training, or work programs whatsoever as a condition of their continued
receipt of, or application for, aid.
The programs may include, but shall not be limited to, service in child
care centers, in preschool programs as teacher aides and in public health
programs as home visitors and health aides; the
maintenance of or services required in connection with public offices,
buildings and grounds; state, county and municipal hospitals, forest
preserves, parks, playgrounds, streets and highways, and other
governmental maintenance or construction directed toward environmental
improvement; and similar facilities.
The Illinois Department or local governmental units may enter into agreements
with local taxing bodies and private not-for-profit organizations, agencies
and institutions to provide for the supervision and administration of job
search, work and training projects authorized by this Section. Such agreements
shall stipulate the requirements for utilization of recipients in such
projects. In addition to any other requirements dealing with the
administration of these programs, the Department shall assure, pursuant to
rules and regulations, that:
(a) Recipients may not displace regular employees.
(b) The maximum number of hours of mandatory work is | ||
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(c) The maximum number of hours per month shall be | ||
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(d) The recipient shall be provided or compensated | ||
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(e) Appropriate terms regarding recipient | ||
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Local taxing bodies and private not-for-profit organizations, agencies
and institutions which utilize recipients in job search, work and training
projects authorized by this Section are urged to include such recipients in the
formulation of their employment policies.
Unless directly paid by an employing local taxing body or not-for-profit
agency, a recipient participating in a work project who meets all requirements
set forth by the Illinois Department shall receive credit towards his or
her monthly assistance benefits for work performed based upon the applicable
minimum wage rate. Where a recipient is paid directly by an employing agency,
the Illinois Department or local governmental unit shall provide for payment
to such employing entity the appropriate amount of assistance benefits to
which the recipient would otherwise be entitled under this Code.
The Illinois Department or its designee, including local governmental units,
may enter into agreements with the agencies or institutions providing work
under programs established hereunder for payment to each such employer
(hereinafter called "public service employer") of all or a portion of the
wages to be paid to persons for the work performed and other appropriate costs.
If the number of persons receiving aid under Article VI is insufficient
to justify the establishment of job search, training and work programs
on a local basis by a local governmental unit, or if for other good cause the
establishment of a local program is impractical or unwarranted, the local
governmental unit shall cooperate with other local governmental units, with
civic and non-profit community agencies, and with the Illinois Department in
developing a program or programs which will jointly serve the participating
governmental units and agencies.
A local governmental unit receiving State funds shall refer all
recipients able to engage in employment to such job search, training and work
programs as are established, whether within or without the governmental
unit, and as are accessible to persons receiving aid from the governmental
unit. The Illinois Department shall withhold allocation of state funds to
any governmental unit which fails or refuses to make such referrals.
Participants in job search, training and work programs shall be required
to maintain current registration for regular employment under Section 11-10
and to accept any bona fide offer of regular employment. They shall
likewise be required to accept education, work and training opportunities
available to them under other provisions of this Code or Federal law. The
Illinois Department or local governmental unit shall provide by rule for
periodic review of the circumstances of each participant to determine the
feasibility of his placement in regular employment or other work, education
and training opportunities.
Moneys made available for public aid purposes under Articles IV
and VI may be expended to pay public service employers all or a
portion of the wages of public service employees and other appropriate
costs, to provide necessary supervisory personnel and equipment, to
purchase Workers' Compensation Insurance or to pay Workers' Compensation
claims, and to provide transportation to and from work sites.
The Department shall provide through rules and regulations for sanctions
against applicants and recipients of aid under this Code who fail to cooperate
with the regulations and requirements established pursuant to this Section.
Such sanctions may include the loss of eligibility to receive aid under
Article VI of this Code for up to 3 months.
The Department, in cooperation with a local governmental unit, may maintain
a roster of persons who are required to participate in a local job search,
training and work program. In such cases, the roster shall be available
for inspection by employers for the selection of possible workers.
In addition to the programs authorized by this Section, the Illinois
Department is authorized to administer any job search, training or work
projects in conjunction with the Federal Food Stamp Program, either under
this Section or under other regulations required by the Federal government.
The Illinois Department may also administer pilot programs to provide job
search, training and work programs to unemployed parents of children
receiving child support enforcement services under Article X of this
Code.
(Source: P.A. 92-111, eff. 1-1-02; 92-590, eff. 7-1-02.)
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(305 ILCS 5/9-6.01) (from Ch. 23, par. 9-6.01)
Sec. 9-6.01.
(Repealed).
(Source: P.A. 86-909. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6.02) (from Ch. 23, par. 9-6.02)
Sec. 9-6.02.
(Repealed).
(Source: P.A. 86-1028. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6.03) (from Ch. 23, par. 9-6.03)
Sec. 9-6.03.
(Repealed).
(Source: P.A. 87-1116. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6.04)
Sec. 9-6.04.
(Repealed).
(Source: P.A. 88-170. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6.1) (from Ch. 23, par. 9-6.1)
Sec. 9-6.1. Housing Education Program.
The Illinois Department shall establish,
either directly or by contract, a pilot project for a housing education
program that will provide persons receiving aid under Articles III, IV, V,
and
VI with instructions in the care and maintenance of dwelling units,
in the essentials of adequate housekeeping, and the problems of urban
living. If in accord with Federal law and regulations governing grants to
this State for public aid purposes, the Department may require recipients
to attend a housing education program. Non-recipients to whom services have
been extended under the provisions of Section 9-8 may also attend and
participate in a housing education program established hereunder.
(Source: P.A. 92-111, eff. 1-1-02; 93-632, eff. 2-1-04.)
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(305 ILCS 5/9-6.2) (from Ch. 23, par. 9-6.2)
Sec. 9-6.2.
Township assistance to county convalescent homes.
In
counties under township organization, the several townships therein which
do not receive State funds for general assistance may provide, from moneys received
and collected for public aid to all persons eligible therefor under
Article VI of this Code, funds for the operation costs of any county
convalescent home in the county, in addition to payment of patient expenses
otherwise provided for under this Code. No township which receives State
funds for general assistance may use moneys received and collected for public aid for
such assistance to county convalescent homes. "County convalescent
home" shall refer to any facility that was established by a county
according to the provisions of Division 5-21 of the Counties Code or its
predecessor.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-6.3) (from Ch. 23, par. 9-6.3)
Sec. 9-6.3.
(Repealed).
(Source: P.A. 86-1028. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/9-6.4) (from Ch. 23, par. 9-6.4)
Sec. 9-6.4.
(Repealed).
(Source: P.A. 85-1209. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/9-7) (from Ch. 23, par. 9-7)
Sec. 9-7.
Establishing Services Not Otherwise Available-State Supervision of
Services in Local Units Receiving State Funds.
Where the services or facilities authorized by Sections 9-3 or 9-5 are
not available or insufficient to meet needs, the Illinois Department or
local governmental unit may establish and provide such services and
facilities. If the local governmental unit receives State funds for such
services or facilities under Sections 9-3 or 9-5, or for any local or joint
programs under Section 9-6, the establishment of such services, facilities
or programs and the expenditure of funds therefor shall be subject to the
approval and supervision of the Illinois Department.
(Source: P.A. 77-1802.)
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(305 ILCS 5/9-8) (from Ch. 23, par. 9-8)
Sec. 9-8. Extension of Coverage.) If appropriate and sufficient facilities
are not available through
other agencies, the Illinois
Department may extend those services provided in this Article which
relate to work adjustment, education, training, and counseling and
guidance on problems of child care, family relationships, home and money
management, transportation, and health, to one or both of the following:
(1) persons and families who have been recipients of | ||
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(2) other persons and families who request the | ||
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The services may be continued for such time as may be necessary to
overcome the conditions which may result in dependency upon financial
aid but each case shall be reviewed at least quarterly to assure that
the services are not continued beyond a reasonable period of time.
Any extension of services under the foregoing provisions shall be
limited to a pilot county or counties, or other test area, until the
cost and effectiveness of the services provided are determined to be in
the public interest.
The Illinois Department may also extend the educational and
vocational training programs provided under Section 9-5 or Section 9-7
to persons whose income does not exceed the standard established to
determine eligibility for aid as a medically indigent person under
Article V, subject to the minimum quarterly review requirement
established in this Section for persons designated in subparagraphs (1)
and (2).
(Source: P.A. 93-632, eff. 2-1-04.)
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(305 ILCS 5/9-9) (from Ch. 23, par. 9-9)
Sec. 9-9.
The Illinois Department shall make information
available in its local
offices informing clients about programs concerning substance use disorder and prevention programs.
(Source: P.A. 100-759, eff. 1-1-19.)
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(305 ILCS 5/9-10) (from Ch. 23, par. 9-10)
Sec. 9-10.
(Repealed).
(Source: P.A. 87-528. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9-11) (from Ch. 23, par. 9-11)
Sec. 9-11.
The Illinois Department may make disbursements to any attorney,
or advocate working under the supervision of an attorney, who represents a
recipient of cash assistance under Article VI in a program administered by the
Illinois Department, in an appeal of any claim for federal veterans'
benefits before a hearing officer at a Veterans' Administration Regional
Office or upon an initial appeal to the Board of Veterans' Appeals which is
decided in favor of the recipient. The amount of the disbursement shall be
equal to the disbursement awarded under Section 3-13 of this Code. No
disbursement shall be made unless a petition and a copy of the favorable
decision is submitted by an attorney or advocate to the Illinois Department
within 60 days of the date of the favorable decision. The disbursement
shall be made within 30 days after the petition is received. The Illinois
Department shall promulgate rules and regulations necessary to implement
this Section.
(Source: P.A. 89-21, eff. 7-1-95.)
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(305 ILCS 5/9-12)
Sec. 9-12.
(Repealed).
(Source: P.A. 88-412; Repealed by P.A. 91-599, eff. 8-14-99.)
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(305 ILCS 5/9-13)
Sec. 9-13. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/9-14) Sec. 9-14. Small business grant program. Subject to appropriation, the Department of Commerce and Economic Opportunity may establish a small business grant program for public aid recipients who are interested in developing a new start-up business. Grant applicants must submit an initial business plan or proposal to the Department of Commerce and Economic Opportunity that clearly articulates the viability of the new start-up business and how the grant money will be used to develop the business. The Department of Commerce and Economic Opportunity shall use such application materials to determine an applicant's eligibility under the program, the grant amount to be awarded, if applicable, and the number of grants an eligible applicant will receive under the program. If an applicant is determined by the Department of Commerce and Economic Opportunity to be eligible for a small business grant, the applicant must submit to the Department of Commerce and Economic Opportunity every year that he or she participates in the program or applies for a new grant an updated business plan or proposal that demonstrates the continued viability or progress of the new start-up business. The Department of Commerce and Economic Opportunity shall adopt any rules necessary to implement this provision, including rules on the minimum and maximum grant amounts awarded under the program, the number of grants an applicant may apply for or receive during a specified period of time, and application requirements.
(Source: P.A. 100-347, eff. 1-1-18.) |
(305 ILCS 5/9-15) Sec. 9-15. Township food pantries. In a county under township organization, a township may provide, from moneys received and collected for public aid to all persons eligible therefor under Article VI of this Code, funds and administer programs for providing in-kind aid in meeting basic maintenance requirements, including, but not limited to, food, paper goods, toiletries, and clothing, to persons who are poor, indigent, homeless, or in need of immediate assistance, in addition to financial aid provided under this Code.
(Source: P.A. 101-309, eff. 1-1-20.) |
(305 ILCS 5/Art. IXA heading) ARTICLE IXA.
EDUCATION, TRAINING AND
EMPLOYMENT PROGRAM FOR RECIPIENTS
UNDER ARTICLE IV
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(305 ILCS 5/9A-1) (from Ch. 23, par. 9A-1)
Sec. 9A-1.
Declaration of Purpose.
It is the purpose of this Article
to provide recipients of public aid under Article IV
the education, training and employment
programs that will help them avoid long-term welfare dependence.
(Source: P.A. 86-1184; 86-1381.)
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(305 ILCS 5/9A-2) (from Ch. 23, par. 9A-2)
Sec. 9A-2.
As used in this Article only, "recipient" means only those
persons receiving aid under Article IV.
(Source: P.A. 86-1184; 86-1381.)
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(305 ILCS 5/9A-2a) Sec. 9A-2a. Federal poverty level; definition. As used in this Article, "federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department
of Health and Human Services under the authority of 42 U.S.C. 9902(2).
(Source: P.A. 102-491, eff. 8-20-21.) |
(305 ILCS 5/9A-3) (from Ch. 23, par. 9A-3)
Sec. 9A-3. Establishment of Program and Level of Services.
(a) The Illinois Department shall establish and maintain a program to
provide recipients with services consistent with the purposes and
provisions of this Article. The program offered in different counties of
the State may vary depending on the resources available to the State to
provide a program under this Article, and no program may be offered in some
counties, depending on the resources available. Services may be provided
directly by the Illinois Department or through contract. References to the
Illinois Department or staff of the
Illinois Department shall include contractors when the Illinois Department
has entered into contracts for these purposes. The Illinois Department
shall provide each
recipient who participates with such services available under the program
as are necessary to achieve his employability plan as specified in the
plan.
(b) The Illinois Department, in operating the program, shall cooperate
with public and private education and vocational training or retraining
agencies or facilities, the Illinois State Board of Education, the Illinois
Community College Board, the Departments of Employment
Security and Commerce and Economic Opportunity or other sponsoring
organizations funded under the federal Workforce
Innovation and Opportunity Act
and other public or licensed private employment agencies.
(Source: P.A. 100-477, eff. 9-8-17.)
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(305 ILCS 5/9A-4) (from Ch. 23, par. 9A-4)
Sec. 9A-4. Participation.
(a) Except for those exempted under subsection (b) below, and to the
extent resources permit, the Illinois Department as a condition of
eligibility for public aid, may, as provided by rule, require all
recipients to participate in an education, training, and employment
program, which shall include accepting suitable employment and refraining
from terminating employment or reducing earnings without good cause.
(b) Recipients shall be exempt from the requirement of
participation in the education, training, and employment program
in the following circumstances:
(1)
The recipient is a person over age 60; or
(2) The recipient is a person with a child under age | ||
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Recipients are entitled to request a reasonable modification to the requirement of participation in the education, training and employment program in order to accommodate a qualified individual with a disability as defined by the Americans with Disabilities Act. Requests for a reasonable modification shall be evaluated on a case-by-case functional basis by designated staff based on Department rule. All such requests shall be monitored as part of the agency's quality assurance process or processes to attest to the expediency with which such requests are addressed. Implementation of the changes made to this Section by this amendatory Act of the 94th General Assembly is subject to appropriation.
(Source: P.A. 94-629, eff. 1-1-06.)
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(305 ILCS 5/9A-5) (from Ch. 23, par. 9A-5)
Sec. 9A-5.
Exempt recipients.
(a) Exempt recipients under Section 9A-4 may volunteer to participate.
(b) Services will be offered to exempt and non-exempt individuals who
wish to volunteer to participate only to the extent resources permit.
(c) Exempt and
non-exempt individuals who volunteer to participate become program
participants upon completion of the initial assessment, development of the
employability plan, and assignment to a component.
An exempt individual who volunteers to participate may not be sanctioned for
not meeting program requirements.
(Source: P.A. 92-111, eff. 1-1-02; 93-598, eff. 8-26-03.)
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(305 ILCS 5/9A-6) (from Ch. 23, par. 9A-6)
Sec. 9A-6.
(Repealed).
(Source: P.A. 86-1475. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/9A-7) (from Ch. 23, par. 9A-7)
Sec. 9A-7. Good cause and pre-sanction process.
(a) The Department shall establish by rule what constitutes good cause
for failure to participate in education, training and employment programs,
failure to accept suitable employment or terminating employment or reducing
earnings.
The Department shall establish, by rule, a pre-sanction process to assist
in resolving disputes over proposed sanctions and in determining if good cause
exists.
Good cause shall include, but not be limited to:
(1) temporary illness for its duration;
(2) court required appearance or temporary | ||
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(3) (blank);
(4) death in the family;
(5) (blank);
(6) (blank);
(7) (blank);
(8) (blank);
(9) extreme inclement weather;
(10) (blank);
(11) lack of any support service even though the | ||
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(12) if an individual is engaged in employment or | ||
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(13) (blank);
(14) failure of Department staff to correctly forward | ||
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(15) failure of the participant to cooperate because | ||
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(16) failure of the participant due to his or her | ||
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(17) failure of the participant because it is | ||
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(18) non-receipt by the participant of a notice | ||
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(19) (blank);
(20) non-comprehension of English, either written or | ||
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(21) (blank);
(22) (blank);
(23) child care (or day care for an incapacitated | ||
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(24) failure to participate in an activity due to a | ||
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(25) if an individual or family is experiencing | ||
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(26) circumstances beyond the control of the | ||
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(27) (blank);
(28) if an individual or family receives an eviction | ||
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(29) if an individual's or family's utilities are | ||
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(30) if an individual or family receives an utility | ||
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(31) if an individual is exiting a publicly funded | ||
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(b) (Blank).
(c)(1) The Department shall establish a reconciliation procedure to
assist in resolving disputes related to any aspect of participation,
including exemptions, good cause, sanctions or proposed sanctions,
supportive services, assessments, responsibility and service
plans,
assignment to activities, suitability of employment, or
refusals of offers
of employment.
Through the reconciliation process the Department shall have a mechanism to
identify good cause, ensure that the client is aware of the issue, and enable
the client to perform required activities without facing sanction.
(2) A participant may request reconciliation and
receive notice in
writing of a meeting. At least one face-to-face
meeting may be scheduled to
resolve misunderstandings or disagreements related to program participation
and situations which may lead to a potential sanction. The meeting will
address the underlying reason for the dispute and plan a resolution to
enable the individual to participate in TANF employment and work activity
requirements.
(2.5) If the individual fails to appear at the reconciliation meeting
without good cause, the reconciliation is unsuccessful and a sanction shall be
imposed.
(3) The reconciliation process shall continue after
it is determined that
the individual did not have good cause for non-cooperation. Any necessary
demonstration of cooperation on the part of the participant will be part of
the reconciliation process. Failure to demonstrate cooperation will result in immediate
sanction.
(4) For the first instance of non-cooperation, if the client reaches
agreement to cooperate, the client shall be allowed 30 days to demonstrate
cooperation before any sanction activity may be imposed. In any subsequent
instances of non-cooperation, the client shall be provided the opportunity to
show good cause or remedy the situation by immediately complying with the
requirement.
(5) The Department shall document in the case record the proceedings
of the reconciliation and provide the client in writing
with a reconciliation
agreement.
(6) If reconciliation resolves the dispute, no
sanction shall be imposed.
If the client fails to comply with the reconciliation agreement, the
Department shall then immediately impose the original sanction.
If the dispute cannot be resolved
during reconciliation, a sanction shall not be imposed
until the reconciliation process is complete.
(Source: P.A. 101-103, eff. 7-19-19.)
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(305 ILCS 5/9A-8) (from Ch. 23, par. 9A-8)
Sec. 9A-8. Operation of program.
(a) At the time of application or redetermination of eligibility under
Article IV, as determined by rule, the Illinois Department shall provide
information in writing and orally regarding the education, training and
employment program to all applicants and recipients. The information
required shall be established by rule and shall include, but need not be
limited to:
(1) education (including literacy training), | ||
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(1.1) a complete list of all activities that are | ||
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(1.2) the rules concerning the lifetime limit on | ||
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(2) supportive services including child care and the | ||
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(3) the obligation of the Department to provide | ||
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(4) the rights and responsibilities of participants, | ||
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(5) the types and locations of child care services.
(b) The Illinois
Department shall notify the recipient in writing of the opportunity to
volunteer to participate in the program.
(c) (Blank).
(d) As part of the personal plan for achieving employment and
self-sufficiency, the Department shall conduct an individualized assessment
of
the
participant's employability. No participant may be assigned to any
component of the education, training and employment activity
prior to such
assessment. The plan shall
include collection of
information
on the individual's background, proficiencies, skills deficiencies,
education level, work history, employment goals, interests, aptitudes, and
employment preferences, as well as factors affecting employability or
ability to meet participation requirements (e.g., health, physical or
mental limitations, child care, family circumstances, domestic violence, sexual violence,
substance use disorders, and special needs of any child of the individual). As part
of the plan,
individuals and Department staff shall work together to identify any
supportive service needs required to enable the client to participate and
meet the objectives of his or her employability plan. The
assessment may be conducted through various methods such as interviews,
testing, counseling, and self-assessment instruments. In the
assessment process, the Department shall offer to include standard
literacy testing
and a determination of
English language proficiency and shall provide it for those who accept the
offer.
Based on the assessment,
the
individual will be assigned to the appropriate activity. The
decision will be based on a determination of the individual's level of
preparation for employment as defined by rule.
(e) Recipients determined to be exempt may volunteer to participate
pursuant to Section 9A-4 and must be assessed.
(f) As part of the personal plan for achieving employment and
self-sufficiency under Section 4-1, an employability plan for recipients
shall be
developed in
consultation with the participant. The Department shall have final
responsibility for approving the employability plan. The employability
plan shall:
(1) contain an employment goal of the participant;
(2) describe the services to be provided by the | ||
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(3) describe the activities, such as component | ||
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(4) describe any other needs of the family that might | ||
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(g) The employability plan shall take into account:
(1) available program resources;
(2) the participant's support service needs;
(3) the participant's skills level and aptitudes;
(4) local employment opportunities; and
(5) the preferences of the
participant.
(h) A reassessment shall be conducted to assess a participant's
progress and to review the employability plan on the following occasions:
(1) upon completion of an activity and before | ||
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(2) upon the request of the participant;
(3) if the individual is not cooperating with the | ||
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(4) if the individual has failed to make satisfactory | ||
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Based on the reassessment, the Department may revise the employability
plan of the participant.
(Source: P.A. 102-1100, eff. 1-1-23.)
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(305 ILCS 5/9A-8.1)
Sec. 9A-8.1.
Improvement of information to applicants and recipients.
The
Illinois Department shall annually review
all procedures and written materials that it has in place for purposes of
compliance with subsection (a) of Section 9A-8 and
Section 11-20.1 requiring the Illinois Department to provide full and timely
information to applicants and recipients of aid under
Article IV of this Code about their opportunities, rights and responsibilities
under the Temporary Assistance for Needy Families
program and related programs. As part of this annual review, the Illinois
Department shall provide copies of all procedures and
materials to the Family Self Sufficiency Advisory Council or any successor
advisory body containing a similar number and
assortment of advocates, providers, contractors, clients, and citizens. The
Family Self Sufficiency Advisory Council or successor
advisory body shall review the existing procedures and materials in light of
program rules, recent changes in the law or rules, and
experience in the field, and it shall suggest changes to the Illinois
Department. The Illinois Department shall produce new or
revised procedures and materials, or ratify the existing ones, for use
beginning each October 1. If the Illinois Department rejects
changes suggested by the Family Self Sufficiency Advisory Council, it shall
explain the reasons in a written response.
(Source: P.A. 91-331, eff. 7-29-99.)
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(305 ILCS 5/9A-9) (from Ch. 23, par. 9A-9)
Sec. 9A-9. Program Activities. The Department shall establish
education, training and placement activities by rule. Not all of the same
activities need be provided in each county in the State. Such activities may
include the following:
(a) Education (Below post secondary). In the Education (below post
secondary) activity, the individual receives
information, referral, counseling services and support services to
increase the individual's employment potential. Participants may be
referred to testing, counseling and education resources. Educational
activities will include basic and remedial education; English proficiency
classes; high school or its equivalency or alternative
education at the secondary level; and with any educational program,
structured study time to enhance successful participation.
An individual's participation in an education program such as literacy, basic
adult education, high school equivalency, or a remedial program shall be
limited to 2 years unless the individual also is working or participating in a
work activity approved by the Illinois Department as defined by rule; this
requirement does not apply, however, to students enrolled in high school.
(b) Job Skills Training (Vocational). Job Skills Training is designed to
increase the individual's ability to obtain and maintain employment. Job
Skills Training activities will include vocational skill classes designed
to increase a participant's ability to obtain and maintain employment. Job
Skills Training may include certificate programs.
(c) Job Readiness. The job readiness activity is designed to enhance
the quality of the individual's level of participation in the world of work
while learning the necessary essentials to obtain and maintain employment.
This activity helps individuals gain the necessary job finding skills to
help them find and retain employment that will lead to economic independence.
(d) Job Search. Job Search may be conducted individually or in groups. Job
Search includes the provision of counseling, job seeking skills training and
information dissemination. Group job search may include training in a group
session. Assignment exclusively to job search cannot be in excess of 8
consecutive weeks (or its equivalent) in any period of 12 consecutive months.
(e) Work Experience. Work Experience assignments may be with private
employers or not-for-profit or public agencies in the State. The Illinois
Department shall provide workers' compensation coverage.
Participants who are not members of a 2-parent assistance unit may not be
assigned more hours than their cash grant amount plus food stamps divided by
the minimum wage. Private employers and not-for-profit and
public agencies shall not use Work Experience participants to displace
regular employees. Participants
in Work Experience may perform work in the public interest (which otherwise
meets the requirements of this Section) for a federal office or agency with
its consent, and notwithstanding the provisions of 31 U.S.C. 1342, or any
other provision
of law, such agency may accept such services, but participants shall
not be considered federal employees for any purpose.
A participant shall be reassessed at the end of
assignment to Work Experience. The participant may be reassigned to Work
Experience or assigned to another activity, based on the
reassessment.
(f) On the Job Training. In On the Job Training, a participant is hired by
a private or public employer and while engaged in productive work receives
training that provides knowledge or skills essential to full and adequate
performance of the job.
(g) Work Supplementation. In work supplementation, the Department pays a
wage subsidy to an employer who hires a participant. The cash grant
which a participant would receive if not employed is diverted
and the diverted cash grant is used to pay the wage subsidy.
(h) Post Secondary Education. Post secondary education must be administered
by an educational institution accredited under requirements of State law.
(i) Self Initiated Education. Participants who are attending
an institution of higher education or a vocational or technical
program of their own choosing and who are in good standing, may continue to
attend and receive supportive services only if the educational program is
approved by the Department, and is in conformity with the participant's
personal plan for achieving employment and self-sufficiency and the participant
is employed part-time, as defined by the Illinois Department by rule.
(j) Job Development and Placement. Department staff shall develop
through contacts with public and private employers unsubsidized job
openings for participants. Job interviews will be secured for clients by
the marketing of participants for specific job openings. Job ready individuals
may be assigned to Job Development and Placement.
(k) Job Retention. The job retention component is designed to assist
participants in retaining employment. Initial employment expenses and job
retention services are provided. The individual's support service needs are
assessed and the individual receives counseling regarding job retention skills.
(l) (Blank).
(l-5) Transitional Jobs. These programs provide temporary wage-paying work
combined with case management and other social services designed to address
employment barriers. The wage-paying work is treated as regular employment for
all
purposes under this Code, and the additional activities, as determined by the
Transitional
Jobs provider, shall be countable work activities. The program must comply with
the
anti-displacement provisions of this Code governing the Work Experience
program.
(m) Pay-after-performance Program. A parent may be required to
participate in a pay-after-performance program in which the parent must work a
specified number of hours to earn the grant. The program shall comply with
provisions of this Code governing work experience programs.
(n) Community Service. Community service includes unpaid work that the
client performs in his or her community, such as for a school, church,
government agency, or nonprofit organization.
(Source: P.A. 98-718, eff. 1-1-15.)
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(305 ILCS 5/9A-9.5)
Sec. 9A-9.5. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 97-48, eff. 6-28-11.)
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(305 ILCS 5/9A-10) (from Ch. 23, par. 9A-10)
Sec. 9A-10.
Support Services.
(a) The Illinois Department shall provide or pay for
child care and other support services, if otherwise unavailable, to
enable recipients to participate
in or prepare for education, training and employment programs authorized
under this Article. The Illinois Department shall provide and pay for such
support services in accordance with procedures, standards and rates
established by rule.
(b) Support services may include:
(1) transportation;
(2) child care;
(3) job search allowance;
(4) initial employment expenses;
(5) required books, fees, supplies; and
(6) required physical examinations and medical | ||
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(c) Participation shall
not be required if support services are needed for effective
participation but unavailable from the Department or some other reasonably
available source. Support services shall be made available to the participant
at no cost.
(Source: P.A. 86-1184; 86-1381; 87-860.)
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(305 ILCS 5/9A-11) (from Ch. 23, par. 9A-11) Sec. 9A-11. Child care. (a) The General Assembly recognizes that families with children need child care in order to work. Child care is expensive and families with limited access to economic resources, including those who are transitioning from welfare to work, often struggle to pay the costs of day care. The General Assembly understands the importance of helping working families with limited access to economic resources become and remain self-sufficient. The General Assembly also believes that it is the responsibility of families to share in the costs of child care. It is also the preference of the General Assembly that all working families with limited access to economic resources should be treated equally, regardless of their welfare status. (b) To the extent resources permit, the Illinois Department shall provide child care services to parents or other relatives as defined by rule who are working or participating in employment or Department approved education or training programs. At a minimum, the Illinois Department shall cover the following categories of families: (1) recipients of TANF under Article IV participating | ||
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(2) families transitioning from TANF to work; (3) families at risk of becoming recipients of TANF; (4) families with special needs as defined by rule; (5) working families with very low incomes as defined | ||
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(6) families that are not recipients of TANF and that | ||
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(7) youth in care, as defined in Section 4d of the | ||
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(8) families receiving Extended Family Support | ||
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(9) families with children under the age of 5 who | ||
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Beginning October 1, 2027, and every October 1 thereafter, the Department of Children and Family Services shall report to the General Assembly on the number of children who received child care via vouchers paid for by the Department of Early Childhood during the preceding fiscal year. The report shall include the ages of children who received child care, the type of child care they received, and the number of months they received child care. The Department shall specify by rule the conditions of eligibility, the application process, and the types, amounts, and duration of services. Eligibility for child care benefits and the amount of child care provided may vary based on family size, income, and other factors as specified by rule. The Department shall update the Child Care Assistance Program Eligibility Calculator posted on its website to include a question on whether a family is applying for child care assistance for the first time or is applying for a redetermination of eligibility. A family's eligibility for child care services shall be redetermined no sooner than 12 months following the initial determination or most recent redetermination. During the 12-month periods, the family shall remain eligible for child care services regardless of (i) a change in family income, unless family income exceeds 85% of State median income, or (ii) a temporary change in the ongoing status of the parents or other relatives, as defined by rule, as working or attending a job training or educational program. In determining income eligibility for child care benefits, the Department annually, at the beginning of each fiscal year, shall establish, by rule, one income threshold for each family size, in relation to percentage of State median income for a family of that size, that makes families with incomes below the specified threshold eligible for assistance and families with incomes above the specified threshold ineligible for assistance. Through and including fiscal year 2007, the specified threshold must be no less than 50% of the then-current State median income for each family size. Beginning in fiscal year 2008, the specified threshold must be no less than 185% of the then-current federal poverty level for each family size. Notwithstanding any other provision of law or administrative rule to the contrary, beginning in fiscal year 2019, the specified threshold for working families with very low incomes as defined by rule must be no less than 185% of the then-current federal poverty level for each family size. Notwithstanding any other provision of law or administrative rule to the contrary, beginning in State fiscal year 2022 through State fiscal year 2023, the specified income threshold shall be no less than 200% of the then-current federal poverty level for each family size. Beginning in State fiscal year 2024, the specified income threshold shall be no less than 225% of the then-current federal poverty level for each family size. In determining eligibility for assistance, the Department shall not give preference to any category of recipients or give preference to individuals based on their receipt of benefits under this Code. Nothing in this Section shall be construed as conferring entitlement status to eligible families. The Illinois Department is authorized to lower income eligibility ceilings, raise parent co-payments, create waiting lists, or take such other actions during a fiscal year as are necessary to ensure that child care benefits paid under this Article do not exceed the amounts appropriated for those child care benefits. These changes may be accomplished by emergency rule under Section 5-45 of the Illinois Administrative Procedure Act, except that the limitation on the number of emergency rules that may be adopted in a 24-month period shall not apply. The Illinois Department may contract with other State agencies or child care organizations for the administration of child care services. (c) Payment shall be made for child care that otherwise meets the requirements of this Section and applicable standards of State and local law and regulation, including any requirements the Illinois Department promulgates by rule. Through June 30, 2026, the rules of this Section include licensure requirements adopted by the Department of Children and Family Services. On and after July 1, 2026, the rules of this Section include licensure requirements adopted by the Department of Early Childhood. In addition, the regulations of this Section include the Fire Prevention and Safety requirements promulgated by the Office of the State Fire Marshal, and is provided in any of the following: (1) a child care center which is licensed or exempt | ||
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(2) a licensed child care home or home exempt from | ||
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(3) a licensed group child care home; (4) other types of child care, including child care | ||
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(c-5) Solely for the purposes of coverage under the Illinois Public Labor Relations Act, child and day care home providers, including licensed and license exempt, participating in the Department's child care assistance program shall be considered to be public employees and the State of Illinois shall be considered to be their employer as of January 1, 2006 (the effective date of Public Act 94-320), but not before. The State shall engage in collective bargaining with an exclusive representative of child and day care home providers participating in the child care assistance program concerning their terms and conditions of employment that are within the State's control. Nothing in this subsection shall be understood to limit the right of families receiving services defined in this Section to select child and day care home providers or supervise them within the limits of this Section. The State shall not be considered to be the employer of child and day care home providers for any purposes not specifically provided in Public Act 94-320, including, but not limited to, purposes of vicarious liability in tort and purposes of statutory retirement or health insurance benefits. Child and day care home providers shall not be covered by the State Employees Group Insurance Act of 1971. In according child and day care home providers and their selected representative rights under the Illinois Public Labor Relations Act, the State intends that the State action exemption to application of federal and State antitrust laws be fully available to the extent that their activities are authorized by Public Act 94-320. (d) The Illinois Department shall establish, by rule, a co-payment scale that provides for cost sharing by families that receive child care services, including parents whose only income is from assistance under this Code. The co-payment shall be based on family income and family size and may be based on other factors as appropriate. Co-payments may be waived for families whose incomes are at or below the federal poverty level. (d-5) The Illinois Department, in consultation with its Child Care and Development Advisory Council, shall develop a plan to revise the child care assistance program's co-payment scale. The plan shall be completed no later than February 1, 2008, and shall include: (1) findings as to the percentage of income that the | ||
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(2) recommendations for revising the child care | ||
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(3) recommendations for revising the child care | ||
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(4) recommendations for changes in child care program | ||
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(e) (Blank). (f) The Illinois Department shall, by rule, set rates to be paid for the various types of child care. Child care may be provided through one of the following methods: (1) arranging the child care through eligible | ||
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(2) arranging with other agencies and community | ||
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(3) (blank); or (4) adopting such other arrangements as the | ||
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(f-1) Within 30 days after June 4, 2018 (the effective date of Public Act 100-587), the Department of Human Services shall establish rates for child care providers that are no less than the rates in effect on January 1, 2018 increased by 4.26%. (f-5) (Blank). (g) Families eligible for assistance under this Section shall be given the following options: (1) receiving a child care certificate issued by the | ||
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(2) if space is available, enrolling the child with a | ||
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(Source: P.A. 102-491, eff. 8-20-21; 102-813, eff. 5-13-22; 102-926, eff. 5-27-22; 103-8, eff. 6-7-23; 103-594, eff. 6-25-24.) |
(305 ILCS 5/9A-11.5) Sec. 9A-11.5. Investigate child care providers. (a) Through June 30, 2026, any child care provider receiving funds from the child care assistance program under this Code who is not required to be licensed under the Child Care Act of 1969 shall, as a condition of eligibility to participate in the child care assistance program under this Code, authorize in writing on a form prescribed by the Department of Children and Family Services, periodic investigations of the Central Register, as defined in the Abused and Neglected Child Reporting Act, to ascertain if the child care provider has been determined to be a perpetrator in an indicated report of child abuse or neglect. The Department of Children and Family Services shall conduct an investigation of the Central Register at the request of the Department of Human Services. (a-5) On and after July 1, 2026, any child care provider receiving funds from the child care assistance program under this Code who is not required to be licensed under the Child Care Act of 1969 shall, as a condition of eligibility to participate in the child care assistance program under this Code, authorize in writing on a form prescribed by the Department of Early Childhood, periodic investigations of the Central Register, as defined in the Abused and Neglected Child Reporting Act, to ascertain if the child care provider has been determined to be a perpetrator in an indicated report of child abuse or neglect. (b) Any child care provider, other than a relative of the child, receiving funds from the child care assistance program under this Code who is not required to be licensed under the Child Care Act of 1969 shall, as a condition of eligibility to participate in the child care assistance program under this Code, authorize in writing a State and Federal Bureau of Investigation fingerprint-based criminal history record check to determine if the child care provider has ever been convicted of a crime with respect to which the conviction has not been overturned and the criminal records have not been sealed or expunged. Upon this authorization, the Department shall request and receive information and assistance from any federal or State governmental agency as part of the authorized criminal history record check. The Illinois State Police shall provide information concerning any conviction that has not been overturned and with respect to which the criminal records have not been sealed or expunged, whether the conviction occurred before or on or after the effective date of this amendatory Act of the 96th General Assembly, of a child care provider upon the request of the Department when the request is made in the form and manner required by the Illinois State Police. The Illinois State Police shall charge a fee not to exceed the cost of processing the criminal history record check. The fee is to be deposited into the State Police Services Fund. Any information concerning convictions that have not been overturned and with respect to which the criminal records have not been sealed or expunged obtained by the Department is confidential and may not be transmitted (i) outside the Department except as required in this Section or (ii) to anyone within the Department except as needed for the purposes of determining participation in the child care assistance program. A copy of the criminal history record check obtained from the Illinois State Police shall be provided to the unlicensed child care provider. (c) The Department shall by rule set standards for determining when to disqualify an unlicensed child care provider for payment because (i) there is an indicated finding against the provider based on the results of the Central Register search or (ii) there is a disqualifying criminal charge pending against the provider or the provider has a disqualifying criminal conviction that has not been overturned and with respect to which the criminal records have not been expunged or sealed based on the results of the fingerprint-based Illinois State Police and Federal Bureau of Investigation criminal history record check. In determining whether to disqualify an unlicensed child care provider for payment under this subsection, the Department shall consider the nature and gravity of any offense or offenses; the time that has passed since the offense or offenses or the completion of the criminal sentence or both; and the relationship of the offense or offenses to the responsibilities of the child care provider. (Source: P.A. 102-538, eff. 8-20-21; 103-594, eff. 6-25-24.) |
(305 ILCS 5/9A-12)
Sec. 9A-12.
(Repealed).
(Source: P.A. 89-641, eff. 8-9-96. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9A-13)
Sec. 9A-13.
Work activity; anti-displacement provisions.
(a) As used in this Section "work activity" means any workfare, earnfare,
pay-after-performance, work-off-the-grant, work experience, or other activity
under Section 9A-9 or any other Section of this
Code in which a
recipient of public assistance performs work for any employer as a condition of
receiving the public assistance, and the employer does not pay wages for the
work; or as any grant diversion, wage supplementation, or similar program in
which the public assistance grant is provided to the employer as a subsidy for
the wages of any recipient in its workforce.
(b) An employer may not utilize a work activity participant if such
utilization would result in:
(1) the displacement or partial displacement of | ||
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(2) the filling of a position that would otherwise be | ||
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(3) the filling of a position created by or causing | ||
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(4) the placement of a participant in any established | ||
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(5) the performance of work by a participant if there | ||
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(c) An employer who wishes to utilize work activity participants shall,
at least 15 days prior to utilizing such participants, notify the
labor organization of the name, work location, and the duties to be performed
by the participant.
(d) The Department of Human Services shall establish a grievance procedure
for employees and labor organizations to utilize in the event of any alleged
violation of this Section. Notwithstanding the above, a labor organization
may utilize the established grievance or arbitration procedure in its
collective bargaining agreement to contest violations of this Section.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/9A-14)
Sec. 9A-14. (Repealed).
(Source: P.A. 91-624, eff. 1-1-00. Repealed by P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/9A-15) Sec. 9A-15. College education assistance; pilot program. (a) Subject to appropriation, the Department of Human Services shall establish a pilot program to provide recipients of assistance under Article IV with additional assistance in obtaining a post-secondary education degree to the extent permitted by the federal law governing the Temporary Assistance for Needy Families Program. This assistance may include, but is not limited to, moneys for the payment of tuition, but the Department may not use any moneys appropriated for the Temporary Assistance for Needy Families Program (TANF) under Article IV to pay for tuition under the pilot program. In addition to criteria, standards, and procedures related to post-secondary education required by rules applicable to the TANF program, the Department shall provide that the time that a pilot program participant spends in post-secondary classes shall apply toward the time that the recipient is required to spend in education, placement, and training activities under this Article. The Department shall define the pilot program by rule, including a determination of its duration and scope, the nature of the assistance to be provided, and the criteria, standards, and procedures for participation. (b) The Department shall enter into an interagency agreement with the Illinois Student Assistance Commission for the administration of the pilot program. (c) The Department shall evaluate the pilot program and report its findings and recommendations after 2 years of its operation to the Governor and the General Assembly, including proposed rules to modify or extend the pilot program beyond the scope and schedule upon which it was originally established.
(Source: P.A. 94-371, eff. 1-1-06; 95-331, eff. 8-21-07.) |
(305 ILCS 5/9A-16) Sec. 9A-16. Work activity; applicable minimum wage. The State or federal minimum wage, whichever is higher, shall be used to calculate the required number of hours of participation in any earnfare or pay-after-performance activity under Section 9A-9 or any other Section of this Code in which a recipient of public assistance performs work as a condition of receiving the public assistance and the recipient is not paid wages for the work.
(Source: P.A. 94-533, eff. 8-10-05; 95-331, eff. 8-21-07.) |
(305 ILCS 5/9A-17) (Section scheduled to be repealed on July 1, 2026) Sec. 9A-17. Smart Start Child Care Program. Subject to appropriation, the Department of Human Services shall establish the Smart Start Child Care Program. The Smart Start Child Care Program shall focus on creating affordable child care, as well as increasing access to child care, for Illinois residents and may include, but is not limited to, providing funding to increase preschool availability, providing funding for childcare workforce compensation or capital investments, and expanding funding for Early Childhood Access Consortium for Equity Scholarships. The Department shall establish program eligibility criteria, participation conditions, payment levels, and other program requirements by rule. The Department of Human Services may consult with the Capital Development Board, the Department of Commerce and Economic Opportunity, and the Illinois Housing Development Authority in the management and disbursement of funds for capital-related projects. The Capital Development Board, the Department of Commerce and Economic Opportunity, and the Illinois Housing Development Authority shall act in a consulting role only for the evaluation of applicants, scoring of applicants, or administration of the grant program. This Section is repealed on July 1, 2026. (Source: P.A. 103-8, eff. 6-7-23; 103-594, eff. 6-25-24.) |
(305 ILCS 5/Art. X heading) ARTICLE X. DETERMINATION AND ENFORCEMENT OF
SUPPORT RESPONSIBILITY OF RELATIVES
(Source: P.A. 103-154, eff. 6-30-23.) |
(305 ILCS 5/10-1) (from Ch. 23, par. 10-1)
Sec. 10-1. Declaration of public policy; persons eligible for child support
enforcement services; fees for non-applicants and
non-recipients. It is the intent of this Code that the financial aid
and social welfare services herein provided supplement rather than
supplant the primary and continuing obligation of the family unit for
self-support to the fullest extent permitted by the resources available
to it. This primary and continuing obligation applies whether the family
unit of parents and children or of husband and wife remains intact and
resides in a common household or whether the unit has been broken by
absence of one or more members of the unit. The obligation of the
family unit is particularly applicable when a member is in necessitous
circumstances and lacks the means of a livelihood compatible with health
and well-being.
It is the purpose of this Article to provide for locating an absent
parent or spouse, for determining his financial circumstances, and for
enforcing his legal obligation of support, if he is able to furnish
support, in whole or in part. The Department of Healthcare and Family Services shall give
priority to establishing, enforcing,
and collecting the current support obligation, and then to past due support
owed to the family unit, except with respect to collections effected
through the intercept programs provided for in this Article. The establishment or enforcement actions provided in this Article do not require a previous court order for custody/allocation of parental responsibilities.
The child support enforcement services provided hereunder
shall be
furnished dependents of an absent parent or spouse who are applicants
for or recipients of financial aid under this Code. It is not,
however, a condition of eligibility for financial aid that there be no
responsible relatives who are reasonably able to provide support. Nor,
except as provided in Sections 4-1.7 and 10-8, shall the existence of
such relatives or their payment of support contributions disqualify a
needy person for financial aid.
By accepting financial aid under this Code, a spouse or a parent or
other person having physical or legal custody of a child shall be deemed to have made
assignment to the Illinois Department for aid under Articles III, IV,
V, and VII or to a local governmental unit for aid under Article VI of
any and all rights, title, and interest in any support obligation, including statutory interest thereon, up to
the amount of financial aid provided. The rights to support assigned to
the Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) or local governmental unit shall
constitute an
obligation owed the State or local governmental unit by the person who
is responsible for providing the support, and shall be collectible under
all applicable processes.
The Department of Healthcare and Family Services shall also furnish the child support enforcement services established under this Article in
behalf of persons who
are not applicants for or recipients of financial aid
under this Code in accordance with the requirements of Title IV, Part D of the
Social Security Act. The Department may
establish a schedule of reasonable fees, to be paid for the services
provided and may deduct a collection fee, not to exceed 10% of the amount
collected, from such collection.
The
Department of Healthcare and Family Services shall cause to be published and
distributed publications
reasonably calculated to inform the public that individuals who are not
recipients of or applicants for public aid under this Code are eligible
for the child support enforcement services under this
Article X. Such
publications
shall set forth an explanation, in plain language, that the child
support enforcement services program is independent of any public
aid program under the Code and that the receiving of child
support
enforcement services in no way implies that the person
receiving such services is receiving
public aid.
(Source: P.A. 102-541, eff. 8-20-21; 102-813, eff. 5-13-22.)
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(305 ILCS 5/10-2) (from Ch. 23, par. 10-2)
Sec. 10-2. Extent of liability. A husband is liable for the support of his
wife and a wife for the support of her husband. Unless the child is otherwise
emancipated, the parents are severally liable for the support of any child
under age 18, and for any child aged 18 who is attending high school, until
that child graduates from high school, or attains the age of 19, whichever is
earlier. The term "child" includes a child born out of wedlock, or legally
adopted child.
The liability for the support of a child provided for in this Article does not require a previous court order for custody and is in conjunction with the guidelines set forth in Section 505 of the Illinois Marriage and Dissolution of Marriage Act, as provided for in Section 10-10 of this Article. The obligation to support contained in this Article is concurrent to any other appropriate State law. This Article does not create, enlarge, abrogate, or diminish parental rights or duties under other laws of this State, including the common law. An action to establish or enforce a support obligation, under this or any other Act providing for the support of a child, may be brought subsequent to an adjudication dismissing that action based on any of the following reasons: (1) no duty of support exists under this Article because this Article requires a previous court order for custody/allocation of parental responsibilities (as no such requirement exists under this Act); (2) there is no common law duty of support (as a common law duty of support is recognized as a valid basis for child support); or (3) there is no duty of support under the Illinois Parentage Act of 2015 because a judgment of paternity results in a de facto custody/allocation of parental responsibilities order (as this ignores the cumulative nature of the Act and the plain language of the statute permitting an explicit reservation of the issue. The Illinois Parentage Act of 2015 will be clarified regarding a de facto custody/allocation of parental responsibilities order as it relates to the Uniform Interstate Family Support Act). In addition to the primary obligation of support imposed upon
responsible relatives, such relatives, if individually or together in any
combination they have sufficient income or other resources to support a
needy person, in whole or in part, shall be liable for any financial aid
extended under this Code to a person for whose support they are
responsible, including amounts expended for funeral and burial costs.
(Source: P.A. 102-541, eff. 8-20-21.)
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(305 ILCS 5/10-3) (from Ch. 23, par. 10-3)
Sec. 10-3.
Standard and Regulations for Determining Ability to Support.
The Illinois Department shall establish a standard by which shall be
measured the ability of responsible relatives to provide support, and shall
implement the standard by rules governing its application. The standard and
the rules shall take into account the buying and consumption patterns of
self-supporting persons of modest income, present or future contingencies
having direct bearing on maintenance of the relative's self-support status
and fulfillment of his obligations to his immediate family, and any unusual
or exceptional circumstances including estrangement or other personal or
social factors, that have a bearing on family relationships and the
relative's ability to meet his support obligations. The standard shall be
recomputed periodically to reflect changes in the cost of living and other
pertinent factors.
In addition to the standard, the Illinois Department may
establish guidelines to be used exclusively to measure the ability of
responsible relatives to provide support on behalf of applicants for or
recipients of financial aid under Article IV of this Act and other persons
who are given access to the child support enforcement
services of this
Article as provided in Section 10-1. In such case, the Illinois Department
shall base the guidelines upon the applicable provisions of Sections 504,
505 and 505.2 of the Illinois Marriage and Dissolution of Marriage Act, as
amended, and shall implement such guidelines by rules governing
their application.
The term "administrative enforcement unit", when used
in this Article, means local governmental units or the Child and Spouse Support
Unit established under Section 10-3.1 when exercising the powers designated in
this Article. The administrative enforcement unit shall apply the standard
or guidelines, rules and procedures provided for by this Section and Sections
10-4 through 10-8 in determining the ability of responsible relatives to
provide support for applicants for or recipients of financial aid under
this Code, except that the administrative enforcement unit may apply such
standard or guidelines, rules and procedures at its discretion with
respect to those applicants for or recipients of financial aid under
Article IV and other persons who are given access to the child
support enforcement services of this Article as provided by Section 10-1.
(Source: P.A. 92-590, eff. 7-1-02; 92-651, eff. 7-11-02.)
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(305 ILCS 5/10-3.1) (from Ch. 23, par. 10-3.1)
Sec. 10-3.1. Child and Spouse Support Unit. The Illinois
Department shall establish within its administrative staff a Child and
Spouse Support Unit to search for and locate absent parents and spouses
liable for the support of persons resident in this State and to exercise
the support enforcement powers and responsibilities assigned the
Department by this Article. The unit shall cooperate with all law
enforcement officials in this State and with the authorities of other
States in locating persons responsible for the support of persons
resident in other States and shall invite the cooperation of these
authorities in the performance of its duties.
In addition to other duties assigned the Child and Spouse Support Unit
by this Article, the Unit may refer to the Attorney General or units of
local government with the approval of the Attorney General, any actions
under Sections 10-10 and 10-15 for judicial enforcement of the support
liability. The Child and Spouse Support Unit shall act for the Department
in referring to the Attorney General support matters requiring judicial
enforcement under other laws. If requested by the Attorney General to so
act, as provided in Section 12-16, attorneys of the Unit may assist the
Attorney General or themselves
institute actions on behalf of the Illinois Department
under the Revised Uniform Reciprocal Enforcement of Support
Act; under the Illinois Parentage Act of
1984 or under the Illinois Parentage Act of 2015; under
the Non-Support of Spouse and Children Act; under the Non-Support Punishment
Act;
or under any other law, State or
Federal, providing for support
of a spouse or dependent child.
The Illinois Department shall also have the authority to enter into
agreements with local governmental units or individuals, with the approval
of the Attorney General, for the collection of moneys owing
because of the failure of a
parent to make child support payments for any child receiving services
under this Article. Such agreements may be on a contingent
fee basis, but such contingent fee shall not exceed 25% of the total amount
collected.
An attorney who provides representation pursuant to this Section shall
represent the
Illinois Department exclusively. Regardless of
the designation of the plaintiff in an action brought pursuant to this Section,
an attorney-client relationship does not exist for purposes of that
action between that attorney
and (i) an applicant for or recipient of child support
enforcement services or
(ii) any other party to the action other than the Illinois Department. Nothing
in this Section shall be construed to modify any power or duty (including a
duty to maintain confidentiality) of the Child and Spouse Support Unit or the
Illinois Department otherwise provided by law.
The Illinois Department may also enter into agreements with local
governmental units for the Child and Spouse Support Unit to exercise the
investigative and enforcement powers designated in this Article,
including the issuance of administrative orders under Section 10-11, in
locating responsible relatives and obtaining support for persons
applying for or receiving aid under Article VI.
Payments for
defrayment of administrative costs and support payments obtained shall
be deposited into the DHS Recoveries Trust Fund. Support
payments shall be paid over to the General Assistance Fund of the local
governmental unit at such time or times as the agreement may specify.
With respect to those cases in which it has support enforcement powers
and responsibilities under this Article, the Illinois Department may provide
by rule for periodic or other review of each administrative and court order
for support to determine whether a modification of the order should be
sought. The Illinois Department shall provide for and conduct such review
in accordance with any applicable federal law and regulation.
As part of its process for review of orders for support, the Illinois
Department, through written notice, may require the responsible relative to
disclose his or her Social Security Number and past and present information
concerning the relative's address, employment, gross wages, deductions from
gross wages, net wages, bonuses, commissions, number of dependent exemptions
claimed, individual and dependent health insurance coverage, and any other
information necessary to determine the relative's ability to provide support in
a case receiving child support enforcement services under
this Article X.
The Illinois Department may send a written request
for the same information to the relative's employer. The employer shall
respond to the request for information within 15 days after the date the
employer receives the request. If the employer willfully fails to fully
respond within the 15-day period, the employer shall pay a penalty of $100 for
each day that the response is not provided to the Illinois Department after the
15-day period has expired. The penalty may be collected in a civil action
which may be brought against the employer in favor of the Illinois Department.
A written request for information sent to an employer pursuant to this
Section shall consist of (i) a citation of this Section as the statutory
authority for the request and for the employer's obligation to provide the
requested information, (ii) a returnable form setting forth the employer's name
and address and listing the name of the employee with respect to whom
information is requested, and (iii) a citation of this Section as the statutory
authority authorizing the employer to withhold a fee of up to $20 from the
wages or income to be paid to each responsible relative for providing the
information to the Illinois Department within the 15-day period. If the
employer is
withholding support payments from the responsible relative's income pursuant to
an order for withholding, the employer may withhold the fee provided for in
this Section only after withholding support as required under the order. Any
amounts withheld from the responsible relative's income for payment of support
and the fee provided for in this Section shall not be in excess of the amounts
permitted under the federal Consumer Credit Protection Act.
In a case receiving child support enforcement services,
the Illinois
Department may request and obtain information from a particular employer under
this Section no more than once in any 12-month period, unless the information
is necessary to conduct a review of a court or
administrative order for support at the request of the person receiving child support enforcement services.
The Illinois Department shall establish and maintain an administrative unit
to receive and transmit to the Child and Spouse Support Unit information
supplied by persons applying for or receiving child support
enforcement services
under Section 10-1. In addition, the Illinois Department shall address and
respond to any alleged deficiencies that persons receiving or applying for
services from the Child and Spouse Support Unit may identify concerning the
Child and Spouse Support Unit's provision of child support
enforcement services.
Within 60 days after an action or failure to act by the Child and Spouse
Support Unit that affects his or her case, a recipient of or applicant for
child support enforcement services under Article X of this
Code may request an
explanation of the Unit's handling of the case. At the requestor's option, the
explanation may be provided either orally in an interview, in writing, or both.
If the Illinois Department fails to respond to the request for an explanation
or fails to respond in a manner satisfactory to the applicant or recipient
within 30 days from the date of the request for an explanation, the
applicant or recipient may request a conference for further review of the
matter by the Office of the Administrator of the Child and Spouse Support Unit.
A request for a conference may be submitted at any time within 60 days after
the explanation has been provided by the Child and Spouse Support Unit or
within 60 days after the time for providing the explanation has expired.
The applicant or recipient may request a conference concerning any decision
denying or terminating child support enforcement services
under Article X of this Code, and the applicant or recipient may also request a
conference concerning the
Unit's failure to provide services or the provision of services in an amount or
manner that is considered inadequate. For purposes of this Section, the Child
and Spouse Support Unit includes all local governmental units or individuals
with whom the Illinois Department has contracted
under Section
10-3.1.
Upon receipt of a timely request for a conference, the Office of the
Administrator shall review the case. The applicant or recipient requesting
the conference shall be entitled, at his or her option, to appear in person or
to participate in the conference by telephone. The applicant or recipient
requesting the conference shall be entitled to be represented and to be
afforded a reasonable opportunity to review the Illinois Department's file
before or at the conference. At the conference, the applicant or recipient
requesting the conference shall be afforded an opportunity to present all
relevant matters in support of his or her claim. Conferences shall be without
cost to the applicant or recipient requesting the conference and shall be
conducted by a representative of the Child or Spouse Support Unit who did not
participate in the action or inaction being reviewed.
The Office of the Administrator shall conduct a conference and inform all
interested parties, in
writing, of the results of the conference within 60 days from the date of
filing of the request for a conference.
In addition to its other powers and responsibilities established by this
Article, the Child and Spouse Support Unit shall conduct an annual assessment
of each institution's program for institution based paternity establishment
under Section 12 of the Vital Records Act.
(Source: P.A. 99-85, eff. 1-1-16.)
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(305 ILCS 5/10-3.2) (from Ch. 23, par. 10-3.2)
Sec. 10-3.2.
Parent Locator Service.
The Illinois Department through
its Child and Spouse Support Unit shall enter into agreements with the
Secretary
of Health and Human Services or his designee under which the services of
the federal Parent Locator Service established by the Social Security Act
are made available to this State and the Illinois Department for the purpose
of locating an absent parent or child when the child has been abducted or
otherwise improperly removed or retained from the physical custody of a
parent or other person entitled to custody of the child, or in connection
with the making or enforcing of a child custody determination in custody
proceedings instituted under the Uniform
Child Custody Jurisdiction Act or the Uniform Child-Custody Jurisdiction
and Enforcement Act,
or otherwise in accordance with law.
The Illinois Department shall provide general information to the public
about the availability and
use of the Parent Locator Service in relation to child abduction and
custody determination proceedings, shall promptly respond to inquiries made
by those parties specified by federal regulations upon receipt of
information as to the location of an absent parent or child from the
federal Parent Locator Service and shall maintain accurate records as to
the number of such inquiries received and processed by the Department.
(Source: P.A. 93-108, eff. 1-1-04.)
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(305 ILCS 5/10-3.3)
Sec. 10-3.3. Locating support obligor and others; penalties.
(a) Upon request by the Child and Spouse Support Unit, employers, labor
unions, cellular telephone companies, and telephone companies shall
provide
location information concerning putative fathers and noncustodial parents for
the purpose of establishing a child's paternity or establishing, enforcing, or
modifying a child support obligation. In this Section, "location information"
means information about (i) the physical whereabouts, including, but not limited to, the home address, home telephone number, cellular telephone number, and e-mail address of a putative father or
noncustodial parent, (ii) the putative father or noncustodial parent's
employer, or
(iii) the salary, wages, and other
compensation paid and the health insurance coverage provided to the putative
father or noncustodial parent by the employer of the putative father or
noncustodial parent
or by a labor union of which the putative father or noncustodial parent is a
member. As used in this Section, "cellular telephone company" includes a cellular telephone or wireless carrier or provider, but does not include a pre-paid wireless carrier or provider. As used in this Section, "physical whereabouts" does not include real time or historical location tracking information.
An employer, labor union, cellular telephone company, or telephone company shall respond to
the request of the Child and Spouse Support Unit within 15 days after
receiving the request. Any
employer, labor union, cellular telephone company, or telephone company that
willfully fails to fully respond within the 15-day period shall be subject to a
penalty of $100 for each day that the response is not provided to the Illinois
Department after the 15-day period has expired. The penalty may be collected
in a civil action, which may be brought against the employer, labor
union, cellular telephone company, or telephone company in
favor of the Illinois Department.
(b) Upon being served with an administrative subpoena as authorized under
this
Code, a utility
company or cable television company must provide location information to the
Child and Spouse
Support Unit for the purpose of establishing a child's paternity or
establishing, enforcing, or
modifying a child support obligation.
(c) Notwithstanding the provisions of any other State or local law to the
contrary, an
employer, labor union, cellular telephone company, telephone company, utility company, or cable television
company shall
not be liable to any person for disclosure of location information under the
requirements of this
Section, except for willful and wanton misconduct.
(Source: P.A. 100-487, eff. 6-1-18.)
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(305 ILCS 5/10-3.4)
Sec. 10-3.4. Obtaining location information.
(a) The Illinois Department shall enter into agreements with the Illinois State Police and the Secretary of State to obtain location information on
persons for the purpose of establishing paternity, and establishing, modifying,
and enforcing child support obligations.
(b) Upon request, the Illinois Department shall provide information obtained
pursuant to this Section to federal agencies and other states' agencies
conducting child support enforcement activities under Title IV, Part D of the
Social Security Act.
(Source: P.A. 102-538, eff. 8-20-21.)
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(305 ILCS 5/10-4) (from Ch. 23, par. 10-4)
Sec. 10-4. Notification of Support Obligation. The administrative enforcement unit within the authorized area of its
operation shall notify each responsible relative of an applicant or recipient,
or responsible relatives of other persons given access to the child support
enforcement services
of this Article, of his legal obligation to support and shall request such
information concerning his financial status as may be necessary to
determine whether he is financially able to provide such support, in whole
or in part. In cases involving a child born out of wedlock, the notification
shall include a statement that the responsible relative has been named as the
biological father of the child identified in the notification.
In the case of applicants, the notification shall be sent as soon as
practical after the filing of the application. In the case of recipients,
the notice shall be sent at such time as may be established by rule of the
Illinois Department.
The notice shall be accompanied by the forms or questionnaires provided
in Section 10-5. It shall inform the relative that he may be liable for
reimbursement of any support furnished from public aid funds prior to
determination of the relative's financial circumstances, as well as for
future support.
In the alternative, when support is sought on
behalf of applicants for or
recipients of financial aid under Article IV of this Code and other persons who
are given access to the child support enforcement services
of this Article as
provided in Section 10-1, the notice shall inform the relative that the
relative may be required to pay support for a period before the date an
administrative support order is entered, as well as future support.
Neither the mailing nor receipt of such notice shall be deemed a
jurisdictional requirement for the subsequent exercise of the investigative
procedures undertaken by an administrative enforcement unit or the entry of
any order or determination of paternity or support or reimbursement
by the
administrative enforcement unit; except that notice shall be served by
certified mail addressed to the responsible relative at his or her last
known address, return receipt requested, or by a person who is licensed or registered as a private detective under the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act of 2004 or by a registered employee of a private detective agency certified under that Act, or in counties with a population of less than 2,000,000 by any method provided by law
for service of summons, in cases where a determination of paternity or
support by default is sought on
behalf of applicants for or recipients of financial aid under Article IV
of this Act and other persons who are given access to the child
support enforcement services of this Article as provided in Section 10-1.
(Source: P.A. 94-92, eff. 6-30-05; 95-613, eff. 9-11-07.)
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(305 ILCS 5/10-5) (from Ch. 23, par. 10-5)
Sec. 10-5. Declarations by Responsible Relatives-Penalty.
Information requested of responsible relatives shall be submitted on
forms or questionnaires prescribed by the Illinois Department or local
governmental units, as the case may be, and shall contain a written
declaration to be signed by the relative in substantially the following
form:
"I declare under penalties of perjury that I have examined this form
(or questionnaire) and all accompanying statements or documents pertaining
to my income, resources, or any other matter having bearing upon my status
and ability to provide support, and to the best of my knowledge and belief
the information supplied is true, correct, and complete".
A person who makes and subscribes a form or questionnaire which
contains, as hereinabove provided, a written declaration that it is made
under the penalties of perjury, knowing it to be false, incorrect or
incomplete, in respect to any material statement or representation bearing
upon his status as a responsible relative, or upon his income, resources,
or other matter concerning his ability to provide support, shall be subject
to the penalties for perjury provided for in Section 32-2 of the Criminal
Code of 2012.
(Source: P.A. 97-1150, eff. 1-25-13.)
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(305 ILCS 5/10-6) (from Ch. 23, par. 10-6)
Sec. 10-6.
Investigation and Determination.
The administrative enforcement unit shall review the forms or
questionnaires returned by each responsible relative and supplement the
information provided therein, where required, by such additional
consultations with the responsible relative and such other investigations
as may be necessary, including genetic testing if paternity is an issue
and, applying the standard or guidelines and
regulations established by the Illinois Department, shall determine whether
and the extent to which, the responsible relative individually or together
in any combination, are reasonably able to provide support.
If the child was born out of wedlock and the case is subject to the voluntary
acknowledgment of paternity or
the administrative determination of paternity under rules established under
Section
10-17.7, the Child and Spouse Support Unit of the Illinois Department shall
determine the child support obligation under subsection (b) of Section 10-7
upon establishing the child's paternity.
If the child's paternity was established by judicial or administrative
process in any other state, the Illinois Department may use administrative
processes contained in this Article X to establish a child support order.
In aid of its investigative authority, the
Child and Spouse Support Unit of the
Illinois Department may use the subpoena power as set forth in
this Article.
The Illinois Department, by rule, may authorize the administrative
enforcement units to conduct periodic or other reinvestigations and
redeterminations of the financial ability of responsible relatives. Any
redeterminations shall have the effect of altering, amending, or modifying
previous determinations and administrative orders entered pursuant to
Sections 10-7 and 10-11. However, any redetermination which
establishes liability for support or reimbursement, or which modifies the
support or reimbursement liability specified in a prior order, shall be
subject to the provisions of Section 10-12 and the administrative and
judicial review procedures herein provided for original orders.
(Source: P.A. 89-641, eff. 8-9-96; 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-7) (from Ch. 23, par. 10-7)
Sec. 10-7.
Notice of support due.
(a) When an administrative enforcement unit has determined that a
responsible relative is financially able to contribute to the support of an
applicant or recipient, the responsible relative shall be notified by
mailing him a copy of the determination by United States registered or
certified mail, advising him of his legal obligation to make support
payments for such period or periods of time, definite in duration or
indefinite, as the circumstances require. The notice shall direct payment
as provided in Section 10-8. Where applicable, the determination and
notice may include a demand for reimbursement for emergency aid granted an
applicant or recipient during the period between the application and
determination of the relative's obligation for support and for aid granted
during any subsequent period the responsible relative was financially able
to provide support but failed or refused to do so.
(b) In the alternative, when support is sought on behalf of
applicants
for or recipients of financial aid under Article IV of this Act and other
persons who are given access to the child support
enforcement services of this
Article as provided in Section 10-1, the administrative enforcement unit shall
not be required to send the notice and may enter an administrative order
immediately under the provisions of Section 10-11. The order shall be based
upon the determination made under the provisions of Section 10-6 or, in
instances of default, upon the needs of the persons for
whom support is sought.
In addition to requiring payment of future support, the administrative order
may require payment of support for a period before the date the order is
entered. The
amount of support to be paid for the prior period shall be determined under the
guidelines established by the Illinois Department pursuant to Section 10-3.
The order shall
direct payment as provided in Section 10-10.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-8) (from Ch. 23, par. 10-8)
Sec. 10-8.
Support Payments - Partial Support - Full Support.
The
notice to responsible relatives issued pursuant to Section 10-7 shall
direct payment (a) to the Illinois Department in cases of applicants and
recipients under Articles III, IV, V and VII, (b) except as provided in
Section 10-3.1, to the local governmental unit in the case of applicants
and recipients under Article VI, and (c) to the Illinois
Department in cases of non-applicants and non-recipients given access to
the child support enforcement services of this Article, as
provided by
Section 10-1. However, if the support payments by responsible relatives
are sufficient to meet needs of a recipient in full, including current
and anticipated medical needs, and the Illinois Department or the local
governmental unit, as the case may be, has reasonable grounds to believe
that such needs will continue to be provided in full by the responsible
relatives, the relatives may be directed to make subsequent support
payments to the needy person or to some person or agency in his behalf
and the recipient shall be removed from the rolls. In such instance the
recipient also shall be notified by registered or certified mail of the
action taken. If a recipient removed from the rolls requests the
Illinois Department to continue to collect the support payments in his
behalf, the Department, at its option, may do so and pay amounts so
collected to the person. The Department may provide for deducting any
costs incurred by it in making the collection from the amount of any
recovery made and pay only the net amount to the person.
Payments under this Section to the Illinois Department pursuant to the
Child Support Enforcement Program established by Title IV-D of the Social
Security Act shall be paid into the Child Support Enforcement Trust Fund.
All payments under this Section to the Illinois Department of Human
Services shall be deposited in the DHS Recoveries
Trust Fund. Disbursements from these funds shall be as provided in Sections
12-9.1 and 12-10.2 of this Code. Payments received by a local
governmental unit shall be deposited in that unit's General Assistance Fund.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall apply.
(Source: P.A. 91-24, eff. 7-1-99; 91-212, eff. 7-20-99; 92-16, eff.
6-28-01; 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-8.1)
Sec. 10-8.1. Temporary order for child support. Notwithstanding any other
law to the contrary, pending the outcome of an
administrative determination of parentage, the Illinois Department shall issue
a temporary order for child support, upon motion by a party and a showing of
clear and convincing evidence of paternity. In determining the amount of the
temporary child support award, the Illinois Department shall use the
guidelines and standards set forth in subsection (a) of Section 505 and in
Section 505.2 of the Illinois Marriage and Dissolution of Marriage Act.
Any new or existing support order entered by the Illinois Department under
this Section shall be deemed to be a series of judgments against the person
obligated to pay support thereunder, each such judgment to be in the amount of
each payment or installment of support and each judgment to be deemed entered
as of the date the corresponding payment or installment becomes due under the
terms of the support order. Each such judgment shall have
the full force, effect, and attributes of any other judgment of this State,
including the ability to be enforced. Any such judgment is subject to
modification or termination only in accordance with Section 510 of the
Illinois Marriage and Dissolution of Marriage Act.
Notwithstanding any other State or local law to the contrary, a lien arises by operation of law against the real and personal property of the
noncustodial parent for each
installment of overdue support owed by the noncustodial parent.
All orders for support entered or modified in a case in which a party is
receiving child support enforcement services under this
Article X shall include
a provision requiring the non-custodial parent to notify the Illinois
Department, within 7 days, (i) of the name, address, and telephone number of
any new
employer of the non-custodial parent, (ii) whether the non-custodial parent has
access to health insurance coverage through the employer or other group
coverage, and, if so, the policy name and number and the names of persons
covered under the policy, and (iii) of any new residential or mailing address
or telephone number of the non-custodial parent.
In any subsequent action to enforce a support order, upon sufficient showing
that diligent effort has been made to ascertain the location of the
non-custodial parent, service of process or provision of notice necessary in
that action may be made at the last known address of the non-custodial parent,
in any manner expressly provided by the Code of
Civil Procedure or this Act, which service shall be sufficient for purposes of
due process.
An order for support shall include a date on which the current support
obligation terminates. The termination date shall be no earlier than the date
on which the child covered by the order will attain the age of
18. However, if the child will not graduate from high school until after
attaining the age
of 18, then the termination date shall be no earlier than the earlier of the
date on which
the child's high school graduation will occur or the date on which the child
will attain the
age of 19. The order for support shall state that the termination
date does not apply to any arrearage that may remain unpaid on that date.
Nothing in this paragraph shall be construed to prevent the Illinois Department
from modifying the order or terminating the order in the event the child is
otherwise emancipated.
If there is an unpaid arrearage or delinquency (as those terms are defined in the Income Withholding for Support Act) equal to at least one month's support obligation on the termination date stated in the order for support or, if there is no termination date stated in the order, on the date the child attains the age of majority or is otherwise emancipated, then the periodic amount required to be paid for current support of that child immediately prior to that date shall automatically continue to be an obligation, not as current support but as periodic payment toward satisfaction of the unpaid arrearage or delinquency. That periodic payment shall be in addition to any periodic payment previously required for satisfaction of the arrearage or delinquency. The total periodic amount to be paid toward satisfaction of the arrearage or delinquency may be enforced and collected by any method provided by law for the enforcement and collection of child support, including but not limited to income withholding under the Income Withholding for Support Act. Each order for support entered or modified on or after the effective date of this amendatory Act of the 93rd General Assembly must contain a statement notifying the parties of the requirements of this paragraph. Failure to include the statement in the order for support does not affect the validity of the order or the operation of the provisions of this paragraph with regard to the order. This paragraph shall not be construed to prevent or affect the establishment or modification of an order for the support of a minor child or the establishment or modification of an order for the support of a non-minor child or educational expenses under Section 513 of the Illinois Marriage and Dissolution of Marriage Act.
(Source: P.A. 97-186, eff. 7-22-11.)
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(305 ILCS 5/10-9) (from Ch. 23, par. 10-9)
Sec. 10-9.
Alternative Actions to Enforce Support.
If a responsible relative fails or refuses to furnish support, or
contributes less than the amount indicated by the determination, the
administrative enforcement unit shall take action to enforce support in
accordance with Section 10-10 or Section 10-11.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-9.5) Sec. 10-9.5. Access to records. In any hearing, case, appeal, or other matter arising out of the provisions concerning the determination and enforcement of the support responsibility of relatives, an obligor or obligee, or their legal representatives, shall be entitled to review any case records in the possession of the Illinois Department of Healthcare and Family Services, the State Disbursement Unit, or a circuit clerk with regard to that obligor or obligee that are able to prove any matter relevant to the hearing, case, appeal, or other matter if access to the record or portion of the record is authorized by 42 U.S.C. 654.
(Source: P.A. 95-685, eff. 10-23-07.) |
(305 ILCS 5/10-10) (from Ch. 23, par. 10-10)
Sec. 10-10. Court enforcement; applicability also to persons who are
not applicants or recipients. Except where the Illinois Department, by
agreement, acts for the local governmental unit, as provided in Section
10-3.1, local governmental units shall refer to the State's Attorney or
to the proper legal representative of the governmental unit, for
judicial enforcement as herein provided, instances of non-support or
insufficient support when the dependents are applicants or recipients
under Article VI. The Child and Spouse Support Unit
established by Section 10-3.1 may institute in behalf of the Illinois
Department any actions under this Section for judicial enforcement of
the support liability when the dependents are (a) applicants or
recipients under Articles III, IV, V or VII; (b) applicants or recipients
in a local governmental unit when the Illinois Department, by agreement,
acts for the unit; or (c) non-applicants or non-recipients who are
receiving child support enforcement services under this Article X, as
provided
in Section 10-1. Where the Child and Spouse Support Unit has exercised
its option and discretion not to apply the provisions of Sections 10-3 through
10-8, the failure by the Unit to apply such provisions shall not be a bar
to bringing an action under this Section.
Action shall be brought in the circuit court to obtain support, or
for the recovery of aid granted during the period such support was not
provided, or both for the obtainment of support and the recovery of the
aid provided. Actions for the recovery of aid may be taken separately
or they may be consolidated with actions to obtain support. Such
actions may be brought in the name of the person or persons requiring
support, or may be brought in the name of the Illinois Department or the
local governmental unit, as the case requires, in behalf of such persons.
The court may enter such orders for the payment of moneys for the
support of the person as may be just and equitable and may direct
payment thereof for such period or periods of time as the circumstances
require, including support for a period before the date the order for support
is entered. The order may be entered against any or all of the defendant
responsible relatives and may be based upon the proportionate ability of
each to contribute to the person's support.
The Court shall determine the amount of child support (including child
support for a period before the date the order for child support is entered)
by
using the
guidelines and standards set forth in subsection (a) of Section 505 and in
Section 505.2 of the Illinois Marriage and Dissolution of Marriage Act.
For purposes of determining the amount of child support to be paid for a
period before the date the order for child support is entered, there is a
rebuttable
presumption that the responsible relative's net income for that period was the
same as his or her net income at the time the order is entered.
If (i) the responsible relative was properly served with a request for
discovery of
financial information relating to the responsible relative's ability to provide
child support, (ii)
the responsible relative failed to comply with the request, despite having been
ordered to
do so by the court, and (iii) the responsible relative is not present at the
hearing to
determine support despite having received proper notice, then any relevant
financial
information concerning the responsible relative's ability to provide child
support
that was
obtained pursuant to subpoena and proper notice shall be admitted into evidence
without
the need to establish any further foundation for its admission.
An order entered under this Section shall include a provision requiring
the obligor to report to the obligee and to the clerk of court within 10 days
each time the obligor obtains new employment, and each time the obligor's
employment is terminated for any reason.
The report shall be in writing and shall, in the case of new employment,
include the name and address of the new employer.
Failure to report new employment or
the termination of current employment, if coupled with nonpayment of support
for a period in excess of 60 days, is indirect criminal contempt. For
any obligor arrested for failure to report new employment bond shall be set in
the amount of the child support that should have been paid during the period of
unreported employment. An order entered under this Section shall also include
a provision requiring the obligor and obligee parents to advise each other of a
change in residence within 5 days of the change
except when the court finds that the physical, mental, or emotional health
of a party or that of a minor child, or both, would be seriously endangered by
disclosure of the party's address.
The Court shall determine the amount of maintenance using the standards
set forth in Section 504 of the Illinois Marriage and Dissolution of Marriage
Act.
Any new or existing support order entered by the court under this
Section shall be deemed to be a series of judgments against the person
obligated to pay support thereunder, each such judgment to be in the amount
of each payment or installment of support and each such judgment to be
deemed entered as of the date the corresponding payment or installment
becomes due under the terms of the support order. Each such judgment shall
have the full force, effect and attributes of any other judgment of this
State, including the ability to be enforced. Any such judgment is subject
to modification or termination only in accordance with Section 510 of the
Illinois Marriage and Dissolution of Marriage Act.
Notwithstanding any other State or local law to the contrary, a lien arises by operation of law against the real and personal property of
the noncustodial parent for each
installment of overdue support owed by the noncustodial parent.
When an order is entered for the support of a minor, the court may
provide therein for reasonable visitation of the minor by the person or
persons who provided support pursuant to the order. Whoever willfully
refuses to comply with such visitation order or willfully interferes
with its enforcement may be declared in contempt of court and punished
therefor.
Except where the local governmental unit has entered into an
agreement with the Illinois Department for the Child and Spouse Support
Unit to act for it, as provided in Section 10-3.1, support orders
entered by the court in cases involving applicants or recipients under
Article VI shall provide that payments thereunder be made
directly to the local governmental unit. Orders for the support of all
other applicants or recipients shall provide that payments thereunder be
made directly to the Illinois Department.
In accordance with federal law and regulations, the Illinois Department may
continue to collect current maintenance payments or child support payments, or
both, after those persons cease to receive public assistance and until
termination of services under Article X. The Illinois Department shall pay the
net amount collected to those persons after deducting any costs incurred in
making
the collection or any collection fee from the amount of any recovery made. In both cases the order shall permit the local
governmental unit or the Illinois Department, as the case may be, to direct
the responsible relative or relatives to make support payments directly to
the needy person, or to some person or agency in his behalf, upon removal
of the person from the public aid rolls or upon termination of services under
Article X.
If the notice of support due issued pursuant to Section 10-7 directs
that support payments be made directly to the needy person, or to some
person or agency in his behalf, and the recipient is removed from the
public aid rolls, court action may be taken against the responsible
relative hereunder if he fails to furnish support in accordance with the
terms of such notice.
Actions may also be brought under this Section in behalf of any
person who is in need of support from responsible relatives, as defined
in Section 2-11 of Article II who is not an applicant for or recipient
of financial aid under this Code. In such instances, the State's
Attorney of the county in which such person resides shall bring action
against the responsible relatives hereunder. If the Illinois
Department, as authorized by Section 10-1, extends the child support
enforcement
services
provided by this Article to spouses and dependent children who are not
applicants or recipients under this Code, the Child and Spouse Support
Unit established by Section 10-3.1 shall bring action against the
responsible relatives hereunder and any support orders entered by the
court in such cases shall provide that payments thereunder be made
directly to the Illinois Department.
Whenever it is determined in a proceeding to establish or enforce a child
support or maintenance obligation that the person owing a duty of support
is unemployed, the court may order the person to seek employment and report
periodically to the court with a diary, listing or other memorandum of his
or her efforts in accordance with such order. Additionally, the court may
order the unemployed person to report to the Department of Employment
Security for job search services or to make application with the local Job
Training Partnership Act provider for participation in job search,
training or work programs and where the duty of support is owed to a child
receiving child support enforcement services under this Article X, the
court may
order the
unemployed person to report to the Illinois Department for participation
in job search, training or work programs established under Section 9-6 and
Article IXA of this Code.
Whenever it is determined that a person owes past-due support for a child
receiving assistance under this Code, the court shall order at the request of
the Illinois Department:
(1) that the person pay the past-due support in | ||
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(2) if the person owing past-due support is | ||
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A determination under this Section shall not be administratively
reviewable by the procedures specified in Sections 10-12, and 10-13 to
10-13.10. Any determination under these Sections, if made the basis of
court action under this Section, shall not affect the de novo judicial
determination required under this Section.
If a person who is found guilty of contempt for failure to comply with an order to pay support is a person who conducts a business or who is self-employed, the court in addition to other penalties provided by law may order that the person do one or more of the following: (i) provide to the court monthly financial statements showing income and expenses from the business or the self-employment; (ii) seek employment and report periodically to the court with a diary, listing, or other memorandum of his or her employment search efforts; or (iii) report to the Department of Employment Security for job search services to find employment that will be subject to withholding of child support. A one-time charge of 20% is imposable upon the amount of past-due child
support owed on July 1, 1988 which has accrued under a support order
entered by the court. The charge shall be imposed in accordance with the
provisions of Section 10-21 of this Code and shall be enforced by the court
upon petition.
All orders for support, when entered or modified, shall
include a provision requiring the non-custodial parent to notify the court and,
in cases in which a party is receiving child support
enforcement services under
this Article X, the Illinois Department, within 7 days, (i) of the name,
address, and telephone number of any new employer of the non-custodial parent,
(ii) whether the non-custodial parent has access to health insurance coverage
through the employer or other group coverage and, if so, the policy name and
number and the names of persons covered under
the policy, and (iii) of any new residential or mailing address or telephone
number of the non-custodial parent. In any subsequent action to enforce a
support order, upon a sufficient showing that a diligent effort has been made
to ascertain the location of the non-custodial parent, service of process or
provision of notice necessary in the case may be made at the last known
address of the non-custodial parent in any manner expressly provided by the
Code of Civil Procedure or this Code, which service shall be sufficient for
purposes of due process.
An order for support shall include a date on which the current support
obligation terminates. The termination date shall be no earlier than the
date on which the child covered by the order will attain the age of
18. However, if the child will not graduate from high school until after
attaining the age
of 18, then the termination date shall be no earlier than the earlier of the
date on which
the child's high school graduation will occur or the date on which the child
will attain the
age of 19. The order for support shall state
that the termination date does not apply to
any arrearage that may remain unpaid on that date. Nothing in this paragraph
shall be construed to prevent the court from modifying the order or terminating
the order in the event the child is otherwise emancipated.
If there is an unpaid arrearage or delinquency (as those terms are defined in the Income Withholding for Support Act) equal to at least one month's support obligation on the termination date stated in the order for support or, if there is no termination date stated in the order, on the date the child attains the age of majority or is otherwise emancipated, then the periodic amount required to be paid for current support of that child immediately prior to that date shall automatically continue to be an obligation, not as current support but as periodic payment toward satisfaction of the unpaid arrearage or delinquency. That periodic payment shall be in addition to any periodic payment previously required for satisfaction of the arrearage or delinquency. The total periodic amount to be paid toward satisfaction of the arrearage or delinquency may be enforced and collected by any method provided by law for the enforcement and collection of child support, including but not limited to income withholding under the Income Withholding for Support Act. Each order for support entered or modified on or after the effective date of this amendatory Act of the 93rd General Assembly must contain a statement notifying the parties of the requirements of this paragraph. Failure to include the statement in the order for support does not affect the validity of the order or the operation of the provisions of this paragraph with regard to the order. This paragraph shall not be construed to prevent or affect the establishment or modification of an order for the support of a minor child or the establishment or modification of an order for the support of a non-minor child or educational expenses under Section 513 of the Illinois Marriage and Dissolution of Marriage Act.
Payments under this Section to the Illinois Department pursuant to the
Child Support Enforcement Program established by Title IV-D of the Social
Security Act shall be paid into the Child Support Enforcement Trust Fund.
All payments under this Section to the Illinois Department of Human
Services shall be deposited in the DHS Recoveries
Trust Fund. Disbursements from these funds shall be as provided in Sections
12-9.1 and 12-10.2 of this Code. Payments received by a local
governmental unit shall be deposited in that unit's General Assistance Fund.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall apply.
(Source: P.A. 97-186, eff. 7-22-11; 97-1029, eff. 1-1-13.)
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(305 ILCS 5/10-10.1) (from Ch. 23, par. 10-10.1)
Sec. 10-10.1.
Public Aid Collection Fee.
In all cases instituted by the
Illinois Department on behalf of a child or spouse, other than one receiving
a grant of financial aid under Article IV, on whose behalf an application
has been made and approved for child support enforcement services as
provided by Section 10-1,
the court shall impose a collection fee on the individual who owes a child
or spouse support obligation in an amount equal to 10% of the amount so
owed as long as such collection is required by federal law, which fee shall
be in addition to the support obligation. The imposition
of such fee shall be in accordance with provisions of Title IV, Part D,
of the Social Security Act and regulations duly promulgated thereunder.
The fee shall be payable to the clerk of the circuit court for transmittal
to the Illinois Department and shall continue until child support
enforcement services are
terminated by the Department.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-10.2) (from Ch. 23, par. 10-10.2)
Sec. 10-10.2.
Notice to Clerk of Circuit Court of Payment
Received by the Illinois Department for Recording. For those cases in which
support is payable to the clerk of the circuit court for transmittal to
the Illinois Department by order of court, and the Illinois Department collects
support by assignment, offset, withholding, deduction or other process permitted
by law, the Illinois Department shall notify the clerk of the date and amount
of such collection.
Upon notification, the clerk shall record the collection on the payment
record for the case.
(Source: P.A. 82-1057.)
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(305 ILCS 5/10-10.3) (from Ch. 23, par. 10-10.3)
Sec. 10-10.3.
For those cases in which child support is payable to the
clerk of the circuit court for transmittal to the Illinois Department by
order of court, the clerk shall transmit all such payments, within 4
working days of receipt, to insure that funds are available for immediate
distribution by the Department to the person or entity entitled thereto in
accordance with standards of the Child Support Enforcement Program established
under Title IV-D of the Social Security Act. The clerk shall notify the
Department of the date of receipt and amount thereof at the time of
transmittal. Where the clerk has entered into an agreement of cooperation
with the Department to record the terms of child support orders and
payments made thereunder directly into the Department's automated data
processing system, the clerk shall account for, transmit and otherwise
distribute child support payments in accordance with such agreement in lieu
of the requirements contained herein.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall apply.
(Source: P.A. 91-212, eff. 7-20-99.)
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(305 ILCS 5/10-10.4)
Sec. 10-10.4. Payment of Support to State Disbursement Unit.
(a) As used in this Section:
"Order for support", "obligor", "obligee", and "payor" mean those terms as
defined in the Income Withholding for Support Act, except that "order for
support" shall not mean orders providing for spousal maintenance under which
there is no child support obligation.
(b) Notwithstanding any other provision of this Code to the contrary, each
court or administrative order for support entered or modified on or after
October 1, 1999 shall require that support payments be made to the State
Disbursement Unit established under Section 10-26 if:
(1) a party to the order is receiving child support | ||
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(2) no party to the order is receiving child support | ||
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(c) Support payments shall be made
to the State Disbursement Unit if:
(1) the order for support was entered before October | ||
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(2) no party to the order is receiving child support | ||
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(c-5) If no party to the order is receiving child support
enforcement services under this Article X, and the support payments are not
being made
through income withholding, then support payments shall be made as directed in
the order for support.
(c-10) At any time, and notwithstanding the existence of an order
directing payments
to be made elsewhere, the Department of Healthcare and Family Services may provide notice to the
obligor and, where applicable, to the obligor's payor:
(1) to make support payments to the State | ||
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(A) a party to the order for support is receiving | ||
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(B) no party to the order for support is | ||
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(2) to make support payments to the State | ||
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(c-15) Within 15 days after the effective date of this amendatory Act of the
91st General Assembly, the clerk of the circuit court shall provide written
notice to the obligor to make payments
directly to the clerk of the circuit court if no party to the order is
receiving child
support enforcement services under this Article X, the support payments are
not made
through income withholding, and the order for support requires support payments
to
be made
directly to the clerk of the
circuit court.
(c-20) If the State Disbursement Unit receives a support payment that was
not
appropriately made to the Unit under this Section, the Unit shall immediately
return the
payment to the sender, including, if possible, instructions detailing where to
send the support payments.
(d) The notices under subsections (c-10) and
(c-15) may be sent by ordinary
mail, certified mail, return receipt requested, facsimile transmission, or
other electronic process, or may be served upon the obligor or payor using any
method provided by law for service of a summons. A copy of the notice shall be
provided to the obligee and, when the order for support
was entered by the court, to the clerk of the court.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/10-10.5)
Sec. 10-10.5.
Information to State Case Registry.
(a) In this Section:
"Order for support", "obligor", "obligee", and "business day" are defined as
set forth in the
Income Withholding for Support Act.
"State Case Registry" means the State Case Registry established under Section
10-27 of this Code.
(b) Each order for support entered or modified by the circuit court under
Section 10-10 shall require that the obligor and obligee (i) file with the
clerk of the circuit court the information required by this Section (and any
other information required under Title IV, Part D of the Social Security Act or
by
the federal Department of Health and Human Services) at the time of entry or
modification
of the order for support and (ii) file updated
information with the clerk within 5 business days of any change.
Failure of the obligor or obligee to file or update the required information
shall be
punishable as in cases of contempt. The failure shall not prevent the court
from entering
or modifying the order for support, however.
(c) The obligor shall file the following information: the
obligor's name, date of birth, social security number, and mailing address.
If
either the obligor or the obligee receives child support enforcement services
from the Illinois Department under Article X of this Code, the obligor shall
also file the following information: the obligor's telephone
number, driver's license number, and residential address (if different from the
obligor's mailing address), and the name, address, and telephone number of the
obligor's employer or employers.
(d) The obligee shall file the following information:
(1) The names of the obligee and the child or | ||
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(2) The dates of birth of the obligee and the child | ||
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(3) The social security numbers of the obligee and | ||
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(4) The obligee's mailing address.
(e) In cases in which the obligee receives child support enforcement
services from the Illinois Department under Article X of this Code, the order
for support shall (i) require that the obligee file the information required
under subsection (d) with the Illinois Department for inclusion in the State
Case Registry, rather than file the information with the clerk, and (ii)
require that the obligee include the following additional information:
(1) The obligee's telephone and driver's license | ||
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(2) The obligee's residential address, if different | ||
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(3) The name, address, and telephone number of the | ||
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The order for support shall also require that the obligee update
the information filed with the Illinois Department within 5 business days of
any change.
(f) The clerk shall provide the information filed under this Section,
together with the court docket number and county in which the order for support
was entered, to the State Case Registry within 5 business days after receipt of
the information.
(g) In a case in which a party is receiving child support enforcement
services under Article X of this Code, the clerk shall provide the following
additional
information to the State Case Registry within 5 business days after entry or
modification of an order for support or request from the Illinois Department:
(1) The amount of monthly or other periodic support | ||
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(2) Any such amounts that have been received by the | ||
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(h) Information filed by the obligor and obligee under this Section that is
not specifically required to be included in the body of an order for support
under other laws is not a public record and shall be treated as
confidential and subject to
disclosure only in accordance with the provisions of this Section, Section
10-27 of this Code, and Title IV, Part D of the Social Security Act.
(Source: P.A. 91-212, eff. 7-20-99; 92-16, eff. 6-28-01; 92-463, eff.
8-22-01; 92-651, eff. 7-11-02.)
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(305 ILCS 5/10-11) (from Ch. 23, par. 10-11)
Sec. 10-11. Administrative Orders. In lieu of actions for court
enforcement of support under Section 10-10, the Child and Spouse Support
Unit of the Illinois Department, in accordance with the rules of the
Illinois Department, may issue an administrative order requiring the
responsible relative to comply with the terms of the determination and
notice of support due, determined and issued under Sections 10-6 and 10-7.
The Unit may also enter an administrative order under subsection (b) of
Section 10-7. The administrative order shall be served upon the
responsible relative by United States registered or certified mail.
In cases in which the responsible relative appeared at the office of the
Child
and Spouse Support Unit in response to the notice of support obligation
issued under Section 10-4, however, or in cases of default in which the notice
was served on the responsible relative by certified mail, return receipt
requested, or by
any
method provided by law for service of summons, the administrative
determination of paternity or administrative support order may be sent to the
responsible relative by ordinary mail addressed to the responsible relative's
last known address.
If a responsible relative or a person receiving child support
enforcement services under this Article fails to petition the Illinois
Department for
release from or modification of the administrative order, as provided in
Section 10-12 or Section 10-12.1, the order shall become final and there
shall be no further
administrative or judicial remedy. Likewise a decision by the Illinois
Department as a result of an administrative hearing, as provided in
Sections 10-13 to 10-13.10, shall become final and enforceable if not
judicially reviewed under the Administrative Review Law, as provided in
Section 10-14.
Any new or existing support order entered by the Illinois Department
under this Section shall be deemed to be a series of judgments against the
person obligated to pay support thereunder, each such judgment to be in the
amount of each payment or installment of support and each such judgment to
be deemed entered as of the date the corresponding payment or installment
becomes due under the terms of the support order. Each such judgment
shall have the full force, effect and attributes of any other judgment of
this State, including the ability to be enforced. Any such judgment is
subject to modification or termination only in accordance with Section 510
of the Illinois Marriage and Dissolution of Marriage Act.
Notwithstanding any other State or local law to the contrary, a lien arises by operation of law against the real and personal property of
the noncustodial parent for each
installment of overdue support owed by the noncustodial parent.
An order for support shall include a date on which the current support obligation terminates. The termination date shall be no earlier than the date on which the child covered by the order will attain the age of majority or is otherwise emancipated. The order for support shall state that the termination date does not apply to any arrearage that may remain unpaid on that date. Nothing in this paragraph shall be construed to prevent modification of the order by the Department. If there is an unpaid arrearage or delinquency (as those terms are defined in the Income Withholding for Support Act) equal to at least one month's support obligation on the termination date stated in the order for support or, if there is no termination date stated in the order, on the date the child attains the age of majority or is otherwise emancipated, then the periodic amount required to be paid for current support of that child immediately prior to that date shall automatically continue to be an obligation, not as current support but as periodic payment toward satisfaction of the unpaid arrearage or delinquency. That periodic payment shall be in addition to any periodic payment previously required for satisfaction of the arrearage or delinquency. The total periodic amount to be paid toward satisfaction of the arrearage or delinquency may be enforced and collected by any method provided by law for the enforcement and collection of child support, including but not limited to income withholding under the Income Withholding for Support Act. Each order for support entered or modified on or after the effective date of this amendatory Act of the 93rd General Assembly must contain a statement notifying the parties of the requirements of this paragraph. Failure to include the statement in the order for support does not affect the validity of the order or the operation of the provisions of this paragraph with regard to the order. This paragraph shall not be construed to prevent or affect the establishment or modification of an order for the support of a minor child or the establishment or modification of an order for the support of a non-minor child or educational expenses under Section 513 of the Illinois Marriage and Dissolution of Marriage Act.
An order for support shall include a date on which the support obligation
terminates. The termination date shall be no earlier than the date on which
the child covered by the order will attain the age of 18. However, if the
child will not graduate from high school until after attaining the age of 18,
then the termination date shall be no earlier than the earlier of the date that
the child's graduation will occur or the date on which the child will attain
the age of 19. The order for support shall state that the termination date
does not apply to any arrearage that may remain unpaid on that date. Nothing
in this paragraph shall be construed to prevent the Illinois Department from
modifying the order or terminating the order in the event the child is
otherwise emancipated.
(Source: P.A. 97-186, eff. 7-22-11.)
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(305 ILCS 5/10-11.1) (from Ch. 23, par. 10-11.1)
Sec. 10-11.1.
(a) Whenever it is determined in a proceeding under
Sections 10-6, 10-7, 10-11 or 10-17.1 that the responsible relative is
unemployed, and support is sought on behalf of applicants for or recipients
of financial aid under Article IV of this Code or other persons who are given
access to the child support enforcement services of this
Article as provided
in Section 10-1, the administrative enforcement unit may order the
responsible relative to report to the Illinois Department for participation
in job search, training or work programs established under Section 9-6 and
Article IXA of this Code or to the Illinois Department of Employment Security
for job search services or to make application with the local Job
Training Partnership Act provider for participation in job search, training or
work programs.
(b) Whenever it is determined that a responsible relative owes past-due
support for a child under an administrative support order entered under
subsection (b) of Section 10-7 or under Section 10-11 or 10-17.1 and the child
is receiving assistance under this Code, the administrative enforcement unit
shall order the following:
(1) that the responsible relative pay the past-due | ||
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(2) if the responsible relative owing past-due | ||
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(Source: P.A. 92-16, eff. 6-28-01; 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-11.2)
Sec. 10-11.2.
Administrative support order information for State Case
Registry.
(a) In this Section, "business day" is defined as set forth in the Income
Withholding for Support Act.
(b) Each administrative support order entered or modified under Section
10-8.1 or Section 10-11 shall require the following:
(1) That the non-custodial parent file with the | ||
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(2) That the custodial parent file with the Illinois | ||
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(c) The non-custodial parent shall file the following information:
(1) The name and date of birth of the non-custodial | ||
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(2) The non-custodial parent's social security | ||
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(3) The mailing address (and the residential address, | ||
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(4) The name, address, and telephone number of the | ||
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(d) The custodial parent shall file the following information:
(1) The names and dates of birth of the custodial | ||
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(2) The social security numbers of the custodial | ||
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(3) The custodial parent's driver's license number | ||
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(4) The custodial parent's mailing address (and | ||
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(5) The name, address, and telephone number of the | ||
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(e) The information filed with the Illinois Department under this Section
shall be included in the State Case Registry established under Section 10-27 of
this Code.
(f) Information filed by the non-custodial parent and custodial parent under
this Section that is not specifically required to be included in the body of an
administrative
support order under other laws or under rules of the Illinois Department shall
be treated as confidential and subject to disclosure only in accordance with
the provisions of this Section, Section 10-27 of this Code, and Title IV, Part
D of
the Social Security Act.
(Source: P.A. 91-212, eff. 7-20-99; 92-463, eff. 8-22-01.)
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(305 ILCS 5/10-12) (from Ch. 23, par. 10-12)
Sec. 10-12.
Petition by responsible relative for release from or
modification of administrative
support order or administrative determination of paternity.
(a) Any responsible
relative aggrieved by an administrative
order entered under Section 10-11 or 10-11.1 or an
administrative determination of paternity entered under Section 10-17.7 who
has been duly notified of
such order or determination may, within 30 days from the date of
mailing of such order or determination,
petition the Illinois Department for a release from or modification of the
order or determination. The day immediately subsequent to the mailing of
the order or determination shall be
considered as the first day, and the day such petition is received by the
Illinois Department shall be considered as the last day in computing the 30
day appeal period.
The Illinois Department shall, upon receipt of a petition within the 30
day appeal period, provide for a hearing to be held thereon.
(b) Notwithstanding the 30-day appeal period set forth in subsection
(a), a man against whom a default administrative determination of paternity
has been entered may have the determination vacated if, within 30 days
after being served with the determination, he appears in person at the office
to which he was given notice to appear for an interview and files a written
request for relief from the determination. The Illinois
Department shall then proceed with the establishment of
paternity. A man may obtain relief under this subsection from an
administrative determination of paternity only once in any proceeding to
establish paternity.
(Source: P.A. 90-790, eff. 8-14-98.)
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(305 ILCS 5/10-12.1)
Sec. 10-12.1.
Petition by person receiving child support
enforcement services for release from or modification of administrative
support order or
administrative determination of paternity. Any person receiving child support
enforcement services under this Article who is aggrieved
by an
administrative order entered under Section 10-11 or 10-11.1 or an
administrative determination of paternity entered under Section 10-17.7
who has been duly notified of the order or determination may, within 30
days after the date of mailing of the order or determination, petition the
Illinois Department for release from or modification of the order or
determination. The day immediately subsequent to the mailing of the order
or determination shall be considered as the first day and the day the petition
is received by the Illinois Department shall be considered as the last day in
computing the 30-day appeal period.
Upon receiving a petition within the 30-day appeal period, the Illinois
Department shall provide for a hearing to be held on the petition.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-13) (from Ch. 23, par. 10-13)
Sec. 10-13.
Hearing on Petition.
The Illinois Department, or any officer or employee thereof designated
in writing by the Illinois Department, shall conduct hearings and
investigations in connection with petitions filed pursuant to
Section
10-12 or Section 10-12.1. Responsible relatives and persons receiving
child support enforcement services under this Article shall
be entitled to
appear in person, to be
represented by counsel at the hearing and to present all relevant matter in
support of their petitions. The provisions of Sections 10-13.1 through 10-13.10
shall govern the hearing.
The hearing shall be de novo and the Illinois Department's determination
of liability or non-liability shall be independent of the determination of
the administrative enforcement unit.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-13.1) (from Ch. 23, par. 10-13.1)
Sec. 10-13.1.
Examination of records.
The Illinois Department, or any properly designated officer or employee
thereof, may examine any books, papers, records or memoranda bearing upon
the determination of ability to support and the order for support and upon
any matter pertinent to the relative's petition and may compel the
attendance and testimony of any person or persons, including the
petitioning responsible relative, having knowledge of matters germane to
the determination order, or the petition.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-13.2) (from Ch. 23, par. 10-13.2)
Sec. 10-13.2.
Hearings not subject to technical rules of evidence or procedure.
In the conduct of any hearing or investigation, neither the Illinois
Department nor a person duly authorized to conduct such hearing or
investigation, shall be bound by the technical rules of evidence, common
law or statutory, or by technical or formal rules of procedure, but shall
conduct the hearing or make the investigation in such manner as seems best
calculated to conform to substantial justice and the spirit of this Code.
No informality in any proceedings, or in the manner of taking testimony,
shall invalidate any order or decision made by the Illinois Department
pursuant to such hearing or investigation.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-13.3) (from Ch. 23, par. 10-13.3)
Sec. 10-13.3.
Authority to administer oaths.
The Illinois Department, or any person duly authorized to conduct such
hearing or investigation, shall have power to administer oaths. Every
person who, having taken an oath or made affirmation before the Illinois
Department, or any duly authorized officer or employee thereof, shall
wilfully swear or affirm falsely, shall be guilty of perjury, and upon
conviction shall be punished accordingly.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-13.4) (from Ch. 23, par. 10-13.4)
Sec. 10-13.4.
Proof of records.)
The books, papers, records and memoranda of the Illinois Department or
of the administrative enforcement unit, or parts thereof, may be proved in
any hearing, investigation, or legal proceeding by a photostatic or other
copy thereof under the certificate of the Director of the Illinois
Department. Such
certified copy shall, without further proof, be admitted into evidence in
the hearing before the Illinois Department or in any other legal
proceeding.
(Source: P.A. 79-474.)
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(305 ILCS 5/10-13.5) (from Ch. 23, par. 10-13.5)
Sec. 10-13.5.
Proof of necessitous circumstances.
Proof in any hearing before the Illinois Department that a person is an
applicant for or recipient of assistance shall be prima facie proof that he
is a "person who is in necessitous circumstances by reason of infirmity,
unemployment, or other cause depriving him of the means of a livelihood
compatible with health and well-being", within the meaning of this Code.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-13.6) (from Ch. 23, par. 10-13.6)
Sec. 10-13.6.
Subpoenas.
(a) The Illinois Department, or any officer or employee thereof
designated
in writing by the Illinois Department, shall at its or his own instance, or
on the written request of any other party to the proceeding, issue
subpoenas requiring the attendance of and the giving of testimony by
witnesses, and subpoenas duces tecum requiring the production of books,
papers, records or memoranda. The subpoenas and subpoenas duces tecum may
be served by any person of full age. Any subpoena may be served in the same
manner as a subpoena issued out of a circuit court, and may also be served
by United States registered or certified mail, addressed to the person
concerned at his last known address, and proof of such mailing shall be
sufficient for the purposes of the Article.
(b) Subpoenas duces tecum issued in other states shall be afforded
full faith and credit in this State. Every such subpoena shall have the full
force, effect, and attributes of a subpoena issued in this State, including the
ability to be enforced.
(Source: P.A. 90-790, eff. 8-14-98.)
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(305 ILCS 5/10-13.7) (from Ch. 23, par. 10-13.7)
Sec. 10-13.7.
Witness fees.
The fees of witnesses for attendance and travel shall be the same as the
fees of witnesses before the Circuit Court of this State; such fees to be
paid when the witness is excused from further attendance. When the witness
is subpoenaed at the instance of the Illinois Department or any employee
thereof, the fees shall be paid in the same manner as other expenses of the
Illinois Department. If the witness is subpoenaed at the instance of any
other party to the proceeding, the Illinois Department may require that the
cost of service of the subpoena or subpoena duces tecum and the fee of the
witness be borne by the party at whose instance the witness is summoned. In
such case, the Illinois Department may require a deposit to cover the cost
of such service and witness fees.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-13.8) (from Ch. 23, par. 10-13.8)
Sec. 10-13.8.
Compelling attendance of witness and production of records.
The circuit court, of the county wherein the
investigation or administrative hearing is held, upon the application of
the Illinois Department or any duly authorized officer or employee thereof,
or upon the application of any other party to the proceeding, may, in its
discretion, compel the attendance of witnesses, the production of
books, papers, records or memorandum and the giving of testimony before the
Illinois Department or any duly authorized officer or employee thereof
conducting an investigation or holding a hearing authorized by this Act, by
an attachment for contempt, or otherwise, in the same manner as production
of evidence may be compelled before the court.
(Source: P.A. 83-334.)
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(305 ILCS 5/10-13.9) (from Ch. 23, par. 10-13.9)
Sec. 10-13.9.
Penalty for non-compliance with subpoena.
Any person who is served with a subpoena or subpoena duces tecum, issued
by the Illinois Department or any duly authorized officer or employee
thereof, to appear and testify or to produce books and papers, in the
course of an investigation or hearing authorized by law, and who refuses or
neglects to appear, or to testify, or to produce books and papers relevant
to such investigation or hearing, as commanded in such subpoena, shall, be
guilty of a Class B misdemeanor.
(Source: P.A. 77-2344.)
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(305 ILCS 5/10-13.10) (from Ch. 23, par. 10-13.10)
Sec. 10-13.10.
Depositions.
The Illinois Department or any duly authorized officer or employee
thereof, or any other party in an investigation or hearing before the
Illinois Department, may cause the depositions of witnesses within or
without the State to be taken in the manner prescribed by law for like
depositions in civil actions in courts of this State, and to that end
compel the attendance of witnesses and the production of books, papers,
records or memoranda.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/10-14) (from Ch. 23, par. 10-14)
Sec. 10-14.
Review of Illinois department decision on petition for hearing.
Any responsible relative or person receiving child support
enforcement services under this Article affected by a final administrative
decision of
the Illinois Department in a hearing, conducted pursuant to Sections 10-13
through 10-13.10 in which such relative or person receiving
services
was a party, may have the decision reviewed
only under and in accordance with the Administrative Review Law, as amended.
The provisions of the Administrative Review Law, and the rules adopted pursuant
thereto, shall apply to and
govern all proceedings for the judicial review of such final administrative
decisions of the Illinois Department. The term "administrative decision"
is defined as in Section 3-101 of the Code of Civil Procedure.
Appeals from all final orders and judgments entered by a court upon
review of the Illinois Department's order in any case may be taken by
either party to the proceeding and shall be governed by the rules
applicable to appeals in civil cases.
The remedy herein provided for appeal shall be exclusive, and no court
shall have jurisdiction to review the subject matter of any order made by
the Illinois Department except as herein provided.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-14.1)
Sec. 10-14.1.
Relief from administrative orders.
Notwithstanding the
30-day appeal period provided in Sections 10-12 and 10-12.1 and the limitation
on review of final administrative decisions contained in Section 10-14, a
responsible relative or a person receiving child support
enforcement services
under this Article who is aggrieved by an administrative order entered under
Section 10-11 or 10-11.1 or an administrative determination of paternity
entered under Section 10-17.7 and who did not petition within the 30-day appeal
period may petition the Illinois Department for relief from the administrative
order or determination on the same grounds as are provided for relief from
judgments
under Section 2-1401 of the Code of Civil Procedure. The petition must be
filed not later than 2 years after the entry of the order or determination by
the Illinois Department. The day immediately subsequent to the mailing of the
order or determination shall be considered as the first day and the day the
petition is received by the Illinois Department shall be considered as the last
day in computing the 2-year period. Any
period during which the person seeking relief is under a legal disability or
duress or during which the grounds for relief are fraudulently concealed shall
be
excluded in computing the period of 2 years.
Upon receiving a petition within the 2-year period, the Illinois Department
shall provide for a hearing to be held on the petition.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-15) (from Ch. 23, par. 10-15)
Sec. 10-15. Enforcement of administrative order; costs and fees. If
a responsible relative refuses, neglects, or fails to comply with a final
administrative support or reimbursement order of the Illinois Department
entered by the Child and Spouse Support Unit pursuant to Sections 10-11 or
10-11.1 or registered pursuant to Section 10-17.1, the Child and Spouse
Support Unit may file suit against the responsible relative or relatives to
secure compliance with the administrative order.
Suits shall be instituted in the name of the People of the State of
Illinois on the relation of the Department of Healthcare and Family Services of the State of
Illinois and the spouse or dependent children for whom the support order
has been issued.
The court shall order the payment of the support obligation, or orders
for reimbursement of moneys for support provided, directly to the Illinois
Department but the order shall permit the Illinois Department to direct the
responsible relative or relatives to make payments of support directly to
the spouse or dependent children, or to some person or agency in his or
their behalf, as provided in Section 10-8 or 10-10, as applicable.
Whenever it is determined in a proceeding to enforce an administrative
order that the responsible relative is unemployed, and support is sought on
behalf of applicants for or recipients of financial aid under Article IV
of this Code or other persons who are given access to the child
support enforcement services of this Article as provided in Section 10-1,
the court may
order the responsible relative to seek employment and report periodically
to the court with a diary, listing or other memorandum of his or her
efforts in accordance with such order. In addition, the court may order
the unemployed responsible relative to report to the Illinois Department for
participation in job search, training or work programs established under
Section 9-6 of this Code or to the Illinois Department of Employment Security
for job search services or to make application with the local Job
Training Partnership Act provider for participation in job search, training or
work programs.
Charges imposed in accordance with the provisions of Section 10-21
shall be enforced by the Court in a suit filed under this Section.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall apply.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/10-15.1) Sec. 10-15.1. Judicial registration of administrative
support orders and administrative paternity orders. (a) A final administrative support order or a final administrative paternity order, excluding a voluntary acknowledgement or denial of paternity that is governed by other provisions of this Code, the Illinois Parentage Act of 2015, and the Vital Records Act, established by the
Illinois Department under this Article X may be registered in
the appropriate circuit court of this State by the Department
or by a party to the order by filing: (1) Two copies, including one certified copy of the | ||
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(2) A sworn statement by the person requesting | ||
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(3) The name of the obligor and, if known, the | ||
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(4) The name of the obligee and the obligee's | ||
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(b) The filing of an administrative support order or an administrative paternity order under
subsection (a) constitutes registration with the circuit
court. (c) (Blank). (c-5) Every notice of registration must be accompanied by a copy of the registered administrative support order or the registered administrative paternity order and the documents and relevant information accompanying the order pursuant to subsection (a). (d) (Blank). (d-5) The registering party shall serve notice of the registration on the other party by first class mail, unless the administrative support order or the administrative paternity order was entered by default or the registering party is also seeking an affirmative remedy. The registering party shall serve notice on the Department in all cases by first class mail. (1) If the administrative support order or the | ||
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(2) If a petition or comparable pleading seeking an | ||
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(e) A notice of registration of an administrative support
order or an administrative paternity order must provide the following information: (1) That a registered administrative order is | ||
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(2) That a hearing to contest enforcement of the | ||
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(3) That failure to contest, in a timely manner, the | ||
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(4) The amount of any alleged arrearages. (f) A nonregistering party seeking to contest enforcement
of a registered administrative support order or a registered administrative paternity order shall request
a hearing within 30 days after the date of service
of notice of the registration. The nonregistering party may
seek to vacate the registration, to assert any defense to an
allegation of noncompliance with the registered administrative
support order or the registered administrative paternity order, or to contest the remedies being sought or the
amount of any alleged arrearages. (g) If the nonregistering party fails to contest the
enforcement of the registered administrative
support order or the registered administrative paternity order in a timely manner, the order shall be confirmed
by operation of law. (h) If a nonregistering party requests a hearing to contest
the enforcement of the registered administrative
support order or the registered administrative paternity order, the circuit court shall schedule the matter for
hearing and give notice to the parties and the Illinois
Department of the date, time, and place of the hearing. (i) A party contesting the enforcement of a registered administrative support order or a registered administrative paternity order or seeking to vacate
the registration has the burden of proving one or more of the
following defenses: (1) The Illinois Department lacked personal | ||
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(2) The administrative support order or the | ||
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(3) The administrative support order or the | ||
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(4) The Illinois Department has stayed the | ||
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(5) There is a defense under the law to the remedy | ||
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(6) Full or partial payment has been made. (j) If a party presents evidence establishing a full or
partial payment defense under subsection (i), the court may
stay enforcement of the registered order, continue the
proceeding to permit production of additional relevant
evidence, and issue other appropriate orders. An uncontested
portion of the registered administrative support order or the registered administrative paternity order may be
enforced by all remedies available under State law. (k) If a contesting party does not establish a defense
under subsection (i) to the enforcement of the
administrative support order or the administrative paternity order, the court shall issue an order
confirming the administrative support order or the administrative paternity order. Confirmation of
the registered administrative support order or the registered administrative paternity order, whether by operation of law or after notice and hearing, precludes further
contest of the order with respect to any matter that could have
been asserted at the time of registration. Upon confirmation,
the registered administrative support order or the registered administrative paternity order shall be treated in
the same manner as a support order or a paternity order entered by the circuit court,
including the ability of the court to entertain a petition to
modify the administrative support order due to a substantial
change in circumstances or a petition to modify the administrative paternity order due to clear and convincing evidence regarding paternity, or petitions for visitation or custody
of the child or children covered by the administrative support
order or the administrative paternity order. Nothing in this Section shall be construed to alter the
effect of a final administrative support order or a final administrative paternity order, or the restriction
of judicial review of such a final order to the provisions of the
Administrative Review Law, as provided in Sections 10-11 and 10-17.7 of this Code.
(l) Notwithstanding the limitations of relief provided for under this Section regarding an administrative paternity order and the administrative relief available from an administrative paternity order under Sections 10-12 through 10-14.1 of this Code, a party may petition for relief from a registered final administrative paternity order entered by consent of the parties, excluding a voluntary acknowledgement or denial of paternity as well as an administrative paternity order entered pursuant to genetic testing. The petition shall be filed pursuant to Section 2-1401 of the Code of Civil Procedure based upon a showing of due diligence and a meritorious defense. The court, after reviewing the evidence regarding this specific type of administrative paternity order entered by consent of the parties, shall issue an order regarding the petition. Nothing in this Section shall be construed to alter the effect of a final administrative paternity order, or the restriction of judicial review of such a final order to the provisions of the Administrative Review Law, as provided in Section 10-17.7 of this Code.(Source: P.A. 99-471, eff. 8-27-15; 100-201, eff. 8-18-17.) |
(305 ILCS 5/10-16) (from Ch. 23, par. 10-16)
Sec. 10-16.
Judicial enforcement of court and administrative support
orders. Court orders entered in proceedings under Section 10-10 and court
orders for enforcement of an administrative order under Section 10-15 and
for the payment of money may be enforced by attachment as for contempt
against the persons of the defendants, and in addition, as other judgments
for the payment of money, and costs may be adjudged against the defendants
and apportioned among them; but if the complaint is dismissed, costs shall
be borne by the Illinois Department or the local governmental unit, as the
case may be. If a responsible relative is directed by the Illinois
Department, or the local governmental unit, under the conditions stated in
Section 10-8, to make
support payments directly to the person, or to some person or agency
in his behalf, the court order entered against him under this Section or
Section 10-10 may be enforced as herein provided if he thereafter fails to
furnish support in accordance with its terms. The State of Illinois shall
not be required to make a deposit for or pay any costs or fees of any court
or officer thereof in any proceeding instituted under this Section.
The provisions of the Civil Practice Law,
and all amendments and modifications thereof, shall apply to and govern all
actions instituted under this Section and Section 10-10.
In such actions proof that a person is an applicant for or recipient of
public aid under any Article of this Code shall be prima facie proof that
he is a person in necessitous circumstances by reason of infirmity,
unemployment or other cause depriving him of the means of a livelihood
compatible with health and well-being.
Payments under this Section to the Illinois Department pursuant to the
Child Support Enforcement Program established by Title IV-D of the Social
Security Act shall be paid into the Child Support Enforcement Trust Fund.
All payments under this Section to the Illinois Department of Human
Services shall be deposited in the DHS Recoveries
Trust Fund. Disbursements from these funds shall be as provided in Sections
12-9.1 and 12-10.2 of this Code. Payments received by a local
governmental unit shall be deposited in that unit's General Assistance Fund.
In addition to the penalties or punishment that may be imposed under this
Section, any person whose conduct constitutes a violation of Section 15 of the
Non-Support Punishment Act may be prosecuted
under that Act,
and
a person convicted under that Act may be sentenced in
accordance with that
Act. The sentence may include but need not be limited to a
requirement
that the person
perform community service under Section 50 of that
Act or
participate in a work alternative program under Section 50 of that
Act. A person may not be required to participate in a work
alternative
program under Section 50 of that Act if
the person is currently
participating in a work program pursuant to Section 10-11.1 of this Code.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall
apply.
(Source: P.A. 91-24, eff. 7-1-99; 91-212, eff.
7-20-99; 92-16, eff. 6-28-01.)
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(305 ILCS 5/10-16.2) (from Ch. 23, par. 10-16.2)
Sec. 10-16.2.
Withholding of Income to Secure Payment of Support.
Orders for support entered under this Code are subject to the Income
Withholding for Support Act.
(Source: P.A. 90-18, eff. 7-1-97; 90-425, eff.
8-15-97; 90-655, eff. 7-30-98; 90-673, eff. 1-1-99; 90-790,
eff. 8-14-98; 91-357, eff. 7-29-99.)
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(305 ILCS 5/10-16.3) (from Ch. 23, par. 10-16.3)
Sec. 10-16.3.
Posting Security, Bond or Guarantee to Secure Payment.
The court may require the responsible relative to post security, bond or
give some other guarantee of a character and amount sufficient to assure
payment of any amount of support due.
(Source: P.A. 84-758.)
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(305 ILCS 5/10-16.4)
Sec. 10-16.4.
Information concerning obligors.
(a) In this Section:
"Arrearage", "delinquency", "obligor", and "order for support" have the
meanings attributed to those terms in the Income Withholding for Support
Act.
"Consumer reporting agency" has the meaning attributed to that term in
Section 603(f) of the Fair Credit Reporting Act, 15 U.S.C. 1681a(f).
(b) Whenever a court of competent jurisdiction finds that an obligor either
owes an arrearage of more than $10,000 or is delinquent in payment of an amount
equal to at least 3 months' support obligation pursuant to an order for
support, the court shall direct the clerk of the court to make information
concerning the obligor available to consumer reporting agencies.
(c) Whenever a court of competent jurisdiction finds that an obligor either
owes an arrearage of more than $10,000 or is delinquent in payment of an amount
equal to at least 3 months' support obligation pursuant to an order for
support, the court shall direct the clerk of the court to cause the obligor's
name and address to be published in a newspaper of general circulation in the
area in which the obligor resides. The clerk shall cause the obligor's name
and address to be published only after sending to the obligor at the obligor's
last known address, by certified mail, return receipt requested, a notice of
intent to publish the information. This subsection (c) applies only if the
obligor resides in the county in which the clerk of the court holds office.
(Source: P.A. 90-466, eff. 1-1-98; 90-673, eff. 1-1-99.)
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(305 ILCS 5/10-16.5)
Sec. 10-16.5. Interest on support obligations. A support obligation, or
any portion of a support obligation, which becomes due and remains unpaid as of the end of each month, excluding the child support that was due for that month to the extent that it was not paid in that month,
shall accrue simple interest as set forth in Section 12-109 of the Code of Civil Procedure.
An order for support entered or modified on or after January 1, 2006 shall
contain a statement that a support obligation required under the order, or any
portion of a support obligation required under the order, that becomes due and
remains unpaid as of the end of each month, excluding the child support that was due for that month to the extent that it was not paid in that month, shall accrue simple interest as set forth in Section 12-109 of the Code of Civil Procedure. Failure to include the statement in the order for support does
not affect the validity of the order or the accrual of interest as provided in
this Section. The Department may provide, by rule, if, or how, the Department will enforce interest in cases in which IV-D services are being provided.
(Source: P.A. 101-336, eff. 8-9-19.)
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(305 ILCS 5/10-16.6)
Sec. 10-16.6.
Electronic Funds Transfer Committee.
(a) The Director of Public Aid shall establish within the Department an
Electronic
Funds Transfer Committee. The Director or his or her designee shall be a member
of the
committee and shall serve as chairperson of the committee. The Director shall
appoint 4
other members of the committee, 2 of whom shall represent employers in this
State and 2
of whom shall represent the banking industry in this State. The administrator
of the State
Disbursement Unit established under Section 10-26 shall be an ex officio member
of the
committee.
(b) The committee shall study ways to modify or expand the use of
electronic
funds transfers for the payment of child support. The committee shall report
its findings
and recommendations to the Governor and the General Assembly before December 1,
2001.
(c) The committee is abolished on December 1, 2001.
(Source: P.A. 91-677, eff. 1-5-00.)
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(305 ILCS 5/10-16.7) Sec. 10-16.7. Child support enforcement debit authorization. (a) For purposes of this Section: "Financial institution" and "account" are defined as set forth in Section 10-24.
"Payor" is defined as set forth in Section 15 of the Income Withholding for Support Act.
"Order for support" means any order for periodic payment of funds to the State Disbursement Unit for the support of a child or, where applicable, for support of a child and a parent with whom the child resides, that is entered or modified under this Code or under the Illinois Marriage and Dissolution of Marriage Act, the Non-Support of Spouse and Children Act, the Non-Support Punishment Act, the Illinois Parentage Act of 1984, or the Illinois Parentage Act of 2015, or that is entered or registered for modification or enforcement under the Uniform Interstate Family Support Act.
"Obligor" means an individual who owes a duty to make payments under an order for support in a case in which child support enforcement services are being provided under this Article X. (b) The Department of Public Aid (now Healthcare and Family Services) shall adopt a child support enforcement debit authorization form that, upon being signed by an obligor, authorizes a financial institution holding an account on the obligor's behalf to debit the obligor's account periodically in an amount equal to the amount of child support that the obligor is required to pay periodically and transfer that amount to the State Disbursement Unit. The form shall include instructions to the financial institution concerning the debiting of accounts held on behalf of obligors and the transfer of the debited amounts to the State Disbursement Unit. In adopting the form, the Department may consult with the Office of Banks and Real Estate and the Department of Financial Institutions. The Department must adopt the form within 6 months after the effective date of this amendatory Act of the 93rd General Assembly. Promptly after adopting the form, the Department must notify each financial institution conducting business in this State that the form has been adopted and is ready for use. (c) An obligor who does not have a payor may sign a child support debit authorization form adopted by the Department under this Section. The obligor may sign a form in relation to any or all of the financial institutions holding an account on the obligor's behalf. Promptly after an obligor signs a child support debit authorization form, the Department shall send the original signed form to the appropriate financial institution. Subject to subsection (e), upon receiving the form, the financial institution shall debit the account and transfer the debited amounts to the State Disbursement Unit according to the instructions in the form. A financial institution that complies with a child support debit authorization form signed by an obligor and issued under this Section shall not be subject to civil liability with respect to any individual or any agency.
(d) The signing and issuance of a child support debit authorization form under this Section does not relieve the obligor from responsibility for compliance with any requirement under the order for support.
(e) A financial institution is obligated to debit the account of an obligor pursuant to this Section only if or to the extent:
(1) the financial institution reasonably believes the | ||
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(2) there are finally collected funds in the account; | ||
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(3) the account is not subject to offsetting claims | ||
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To the extent the account of the obligor is pledged or held by the financial institution as security for a loan or other obligation, or that the financial institution has any other claim or lien against the account, the financial institution is entitled to retain the account.
(Source: P.A. 99-85, eff. 1-1-16.) |
(305 ILCS 5/10-17) (from Ch. 23, par. 10-17)
Sec. 10-17. Other
actions and remedies for support.
The procedures, actions, and remedies provided in this Article shall in
no way be exclusive, but shall be available in addition to other actions
and remedies of support, including, but not by way of limitation, the
remedies provided in (a) the Illinois Parentage Act of 2015; (b) (blank); (b-5) the Non-Support Punishment Act; (c) (blank); (d) the Illinois Marriage and Dissolution of Marriage Act; (e) the Uniform Child-Custody Jurisdiction and Enforcement Act; (f) the Uniform Interstate Family Support Act; and (g) the common law.
This Article does not create, enlarge, abrogate, or diminish parental rights or duties under other laws of this State, including the common law. (Source: P.A. 102-541, eff. 8-20-21.)
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(305 ILCS 5/10-17.05) Sec. 10-17.05. Actions and remedies for support; other laws. Notwithstanding any other State or local law to the contrary, actions and remedies under this Article, the Uniform Interstate Family Support Act, or other State laws shall be cumulative and used in conjunction with one another, as appropriate. Actions and remedies under the Uniform Interstate Family Support Act shall not require a custody or visitation determination as a prerequisite to a determination of a support obligation. If a custody or visitation determination is not permitted under the Uniform Interstate Family Support Act, the determination may be made under another appropriate State law if the court has authority to make the decision under the appropriate law.
(Source: P.A. 102-541, eff. 8-20-21.) |
(305 ILCS 5/10-17.1) (from Ch. 23, par. 10-17.1)
Sec. 10-17.1. Administrative Order by Registration. The Illinois
Department may provide by rule for the administrative registration of a
support order
entered by a court or administrative body of another
state.
The purpose of registration shall be to enforce or modify the order in
accordance with the provisions of the Uniform Interstate Family Support
Act. Upon
registration, such support order shall become an administrative order of
the Child and Spouse Support Unit by operation of law. The rule shall
provide for notice to and an opportunity to be heard by the responsible
relative and custodial parent affected, and any final administrative
decision rendered by the
Department shall be reviewed only under and in accordance with the
Administrative Review Law.
Any new or existing support order registered by the Illinois Department
under this Section shall be deemed to be a series of judgments against the
person obligated to pay support thereunder, each such judgment to be in the
amount of each payment or installment of support and each such judgment to
be deemed entered as of the date the corresponding payment or installment
becomes due under the terms of the support order. Each such judgment
shall be
enforceable in the same manner as any other judgment in this State.
Notwithstanding any other State or local law to the contrary, a lien arises by operation of law against the real and personal property of
the noncustodial parent for each
installment of overdue support owed by the noncustodial parent.
A one-time charge of 20% is imposable upon the amount of past-due child
support owed on July 1, 1988, which has accrued under a support order
registered by the Illinois Department under this Section. The charge shall
be imposed in accordance with the provisions of Section 10-21 and shall be
enforced by the court in a suit filed under Section 10-15.
(Source: P.A. 97-186, eff. 7-22-11.)
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(305 ILCS 5/10-17.2) (from Ch. 23, par. 10-17.2)
Sec. 10-17.2.
Income Withholding By Administrative Order.
The Illinois
Department may provide by rule for entry of an administrative support order
containing income withholding provisions and for service and enforcement of an
income withholding notice and a National Medical Support Notice, by
the Child and
Spouse Support Unit based upon and in the same manner as prescribed by
the Income Withholding for Support Act.
The penalties provided in the Income Withholding for Support Act shall apply
hereto and
shall be enforced by filing an action under that Act.
The rule shall provide for notice to and an opportunity
to be heard by the responsible relative affected and any final
administrative decision rendered by the Department shall be reviewed only
under and in accordance with the Administrative Review Law.
(Source: P.A. 92-590, eff. 7-1-02.)
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(305 ILCS 5/10-17.3) (from Ch. 23, par. 10-17.3)
Sec. 10-17.3. Federal Income Tax Refund Intercept. The Illinois
Department may provide by rule for certification to the United States Department of
Health and Human Services of past due support owed
by responsible relatives under a support order entered by a court or
administrative body of this or any other State on behalf of resident or
non-resident persons. The purpose of certification shall be to intercept
Federal Income Tax refunds due such relatives in order to satisfy such past
due support in whole or in part.
The rule shall provide for notice to and an opportunity to be heard by
the responsible relative affected and any final administrative decision
rendered by the Department shall be reviewed only under and in accordance
with the Administrative Review Law. Certification shall be accomplished in
accordance with Title IV, Part D of the federal Social Security Act and
rules and regulations promulgated thereunder.
(Source: P.A. 100-201, eff. 8-18-17.)
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(305 ILCS 5/10-17.4) (from Ch. 23, par. 10-17.4)
Sec. 10-17.4.
Security, Bond or Guarantee to Secure Payment.
The Illinois
Department may provide by rule for the requiring of, or for the requesting
of the court to require, a responsible relative to post security, bond or give
some other guarantee of a character and amount sufficient to assure payment
of any amount due under a support order entered by a court or
administrative body of this or any other State on behalf of resident or
non-resident persons. The rule shall provide for notice to and an
opportunity to be heard by each responsible relative affected and any final
administrative decision rendered by the Department shall be reviewed only
under and in accordance with the Administrative Review Law.
(Source: P.A. 84-758.)
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(305 ILCS 5/10-17.5) (from Ch. 23, par. 10-17.5)
Sec. 10-17.5.
State Income Tax Refund and Other Payment Intercept.
The
Illinois Department may provide by rule for certification to the
Comptroller of past due support owed by responsible relatives under a
support order entered by a court or administrative body of this or any
other State on behalf of resident or non-resident persons. The purpose of
certification shall be to intercept state income tax refunds and other
payments due such relatives in order to satisfy such past due support, in
whole or in part, whether or not such support is owed to the State. The
rule shall provide for notice to and an opportunity to be heard by the
responsible relative and any joint payee affected and any final
administrative decision rendered by the Department shall be reviewed only
under and in accordance with the Administrative Review Law. In any case
where a state income tax refund is intercepted wrongfully or erroneously,
the Department shall pay to such relative and any joint payee affected the
amount of the refund plus interest, if any, on such amount at the rate of
9% per annum (or at such adjusted rate as is established under Section 6621(b)
of the Internal Revenue Code). Interest shall be calculated from the
date the Department receives the refund or from 60 days following the date
the Department receives a request to be heard, whichever is later, until
the date of payment to such relative and joint payee.
(Source: P.A. 85-1440.)
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(305 ILCS 5/10-17.6) (from Ch. 23, par. 10-17.6)
Sec. 10-17.6. Certification of
Information to Licensing Agencies. (a) The
Illinois Department may provide by rule for certification to any State
licensing agency to suspend, revoke, or deny issuance or renewal of licenses because of (i) the failure of responsible relatives to comply with subpoenas or warrants relating to paternity or child support proceedings and (ii) past due support owed by responsible relatives under a
support order entered by a court or administrative body of this or any
other State on behalf of resident or non-resident persons receiving child support enforcement services under Title IV, Part D of the Social Security Act. The rule shall
provide for notice to and an opportunity to be heard by each responsible
relative affected and any final administrative decision rendered by the
Department shall be reviewed only under and in accordance with the
Administrative Review Law.
(b) The Illinois Department may provide by rule for directing the Secretary of State to issue family financial
responsibility driving permits upon petition of responsible relatives whose driver's licenses have been suspended in accordance with subsection (b) of Section 7-702.1 of the Illinois Vehicle Code. Any final administrative decisions rendered by the Department upon such petitions shall be reviewable only under and in accordance with the
Administrative Review Law. (Source: P.A. 95-685, eff. 10-23-07; 96-1284, eff. 1-1-11.)
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(305 ILCS 5/10-17.7)
Sec. 10-17.7. Administrative determination of paternity. The Illinois
Department may provide by rule for the administrative determination of
paternity by the Child and Spouse Support Unit in cases involving applicants
for or recipients of financial aid under Article IV of this Act and other
persons who are given access to the child support
enforcement services of this
Article as provided in Section 10-1, including persons similarly situated and
receiving similar services in other states. The rules shall extend to cases in
which the mother and alleged father voluntarily acknowledge paternity in the
form required by the Illinois Department or agree
to be bound by the results of genetic testing or in which the alleged
father
has failed to respond to a notification of support obligation issued under
Section 10-4 and to cases of contested paternity. The Illinois
Department's form for voluntary acknowledgement of paternity shall be the same form prepared by the Illinois Department for use under the requirements of Section 12 of the Vital Records Act. Any
presumption provided for under the Illinois Parentage Act of
1984 or under the Illinois Parentage Act of 2015 on and after the effective date of that Act shall apply to cases in which paternity is determined under the rules of
the Illinois Department. The rules shall provide for notice and an opportunity
to be heard by the responsible relative and the person receiving child support enforcement services under this Article if paternity is
not
voluntarily acknowledged, and any final administrative
decision rendered by the Illinois Department shall be reviewed only under and
in accordance with the Administrative Review Law. Determinations of paternity
made by the Illinois Department under the rules authorized by this Section
shall
have the full force and effect of a court judgment of paternity entered under
the Illinois Parentage Act of 1984 or under the Illinois Parentage Act of 2015.
In determining paternity in contested cases, the Illinois Department shall
conduct the evidentiary hearing in accordance with Article 4 of the Illinois Parentage Act of 2015, except that references in that Article to "the court" shall be
deemed to mean the Illinois Department's hearing officer in cases in which
paternity is determined administratively by the Illinois Department.
Notwithstanding any other provision of this Article, a
default determination
of
paternity may be made if service of the notice under Section 10-4 was made by
publication under the rules for administrative paternity determination
authorized by this Section. The rules as they pertain to service by
publication shall (i) be based on the provisions of Section 2-206 and 2-207 of
the Code of Civil Procedure, (ii) provide for service by publication in cases
in which
the whereabouts of the alleged father are unknown after diligent location
efforts by the Child and Spouse Support Unit, and (iii) provide for publication
of a notice of default paternity determination in the same manner that the
notice under Section 10-4 was published.
The Illinois Department
may implement this Section through the use of emergency rules in accordance
with Section 5-45 of the Illinois Administrative Procedure Act. For purposes
of the Illinois Administrative Procedure Act, the adoption of rules to
implement this Section shall be considered an emergency and necessary for
the public interest, safety, and welfare.
(Source: P.A. 99-85, eff. 1-1-16.)
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(305 ILCS 5/10-17.8)
Sec. 10-17.8.
New birth certificate.
The Illinois Department shall notify
the Department
of Public Health of a final determination of parentage and a voluntary
acknowledgment of paternity made under the rules
authorized by Section 10-17.7, and the Department of Public Health shall issue
a new certificate of birth pursuant to Section 17 of the Vital Records Act.
(Source: P.A. 89-6, eff. 3-6-95; 89-641, eff. 8-9-96.)
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(305 ILCS 5/10-17.9)
Sec. 10-17.9. Past due support information to State Department of Revenue.
(a) The Illinois Department may provide by rule for certification to the
Illinois Department of Revenue of past due support owed by responsible
relatives under a support order entered by a court or administrative body of
this or any other State on behalf of resident or non-resident persons. The
rule shall provide for notice to and an opportunity to be heard by each
responsible relative affected. Any final administrative decision rendered by
the Department shall be reviewed only under and in accordance with the
Administrative Review Law. A responsible relative may avoid certification to
the Illinois Department of Revenue by establishing a satisfactory repayment
record as determined by the Illinois Department of Healthcare and Family Services.
(b) A certified past due support amount shall be final. The certified
amount shall be payable to the Illinois Department of Revenue upon written
notification of the certification to the responsible relative by the Illinois
Department of Revenue.
(c) In the event a responsible relative overpays pursuant to collection
under this Section and the applicable Sections of the Illinois Income Tax Act,
the overpayment shall be a credit against future support obligations. If the
current support obligation of the responsible relative has terminated under
operation of law or court order, any moneys overpaid but still in the
possession of the Department shall be promptly returned to the responsible
relative.
(d) Except as otherwise provided in this Article, any child support
delinquency certified to the Illinois Department of Revenue shall be treated as
a child support delinquency for all other purposes, and any collection action
by the State's Attorney or the Illinois Department of Revenue with respect to
any delinquency certified under this Article shall have the same priority
against attachment, execution, assignment, or other collection action as is
provided by any other provision of State law.
(e) Any child support delinquency collected by the Illinois Department of
Revenue, including those amounts that result in overpayment of a child support
delinquency, shall be paid to the State Disbursement Unit established under
Section 10-26.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/10-17.11)
Sec. 10-17.11.
Requests to other states for administrative enforcement.
The Illinois Department may provide by rule for certification to other states'
child support enforcement agencies of past due support owed by responsible
relatives under a support order entered by a court or administrative body of
this or
any other state on behalf of resident or non-resident persons. The purpose
of certification shall be to request the other states' assistance in
administrative enforcement of the support orders. The rule shall provide
for notice to and an opportunity to be heard by the responsible relative
affected and any final administrative decision rendered by the Illinois
Department shall be reviewed only under and in accordance with the
Administrative Review Law.
(Source: P.A. 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-17.12) Sec. 10-17.12. Compromise of assigned child support arrearages. The Department of Healthcare and Family Services may provide by rule for compromise of debt owed to the State in the form of child support arrearages and interest accrued on child support arrearages assigned to the State under Section 10-1. The rule shall establish the circumstances under which such obligations may be compromised, with due regard for the payment ability of low-income obligors and the importance of encouraging payment of current child support obligations. The rule shall provide that assigned obligations shall be compromised only in exchange for regular payment of support owed to the family and shall require that obligors considered for debt compromise demonstrate inability to pay during the time the assigned obligation accumulated. The rule shall provide for nullification of any compromise agreement and the prohibition of any future compromise agreement if the obligor fails to adhere to the compromise agreement. In addition, the rule shall establish debt compromise criteria calculated to maximize positive effects on families and the level of federal incentive payments payable to the State under Title IV, Part D of the Social Security Act and regulations promulgated thereunder.
(Source: P.A. 94-971, eff. 1-1-07.) |
(305 ILCS 5/10-17.13) Sec. 10-17.13. Vehicle immobilization and impoundment. The Illinois Department may provide by rule for certification to municipalities of past due support owed by responsible relatives under a support order entered by a court or administrative body of this or any other State on behalf of resident or non-resident persons. The purpose of certification shall be to effect collection of past due support by immobilization and impoundment of vehicles registered to responsible relatives pursuant to ordinances established by such municipalities under Section 11-1430 of the Illinois Vehicle Code. The rule shall provide for notice to and an opportunity to be heard by each responsible relative affected, and any final administrative decision rendered by the Department shall be reviewed only under and in accordance with the Administrative Review Law. A responsible relative may avoid certification to a municipality for vehicle immobilization or arrange for discontinuance of vehicle immobilization and impoundment already engaged by payment of past due support or by entering into a plan for payment of past and current child support obligations in a manner satisfactory to the Illinois Department.
(Source: P.A. 95-685, eff. 10-23-07.) |
(305 ILCS 5/10-17.14) Sec. 10-17.14. Denial of passports. The Illinois Department may provide by rule for certification to the United States Department of Health and Human Services of past due support owed by responsible relatives under a support order entered by a court or administrative body of this or any other State on behalf of resident or non-resident persons. The purpose of certification shall be to effect denial, revocation, restriction, or limitation of passports of responsible relatives owing past due support. The rule shall provide for notice to and an opportunity to be heard by the responsible relative affected and any final administrative decision rendered by the Department shall be reviewed only under and in accordance with the Administrative Review Law. Certification shall be accomplished in accordance with Title IV, Part D of the federal Social Security Act and rules and regulations promulgated thereunder.
(Source: P.A. 100-201, eff. 8-18-17.) |
(305 ILCS 5/10-17.15) Sec. 10-17.15. Certification of information to State gaming licensees. (a) For purposes of this Section, "State gaming licensee" means, as applicable, an organization licensee or advance deposit wagering licensee licensed under the Illinois Horse Racing Act of 1975, an owners licensee licensed under the Illinois Gambling Act, or a licensee that operates, under any law of this State, one or more facilities or gaming locations at which lawful gambling is authorized and licensed as provided in the Illinois Gambling Act. (b) The Department may provide, by rule, for certification to any State gaming licensee of past due child support owed by a responsible relative under a support order entered by a court or administrative body of this or any other State on behalf of a resident or non-resident receiving child support services under this Article in accordance with the requirements of Title IV-D, Part D, of the Social Security Act. The State gaming licensee shall have the ability to withhold from winnings required to be reported to the Internal Revenue Service on Form W-2G, up to the full amount of winnings necessary to pay the winner's past due child support. The rule shall provide for notice to and an opportunity to be heard by each responsible relative affected and any final administrative decision rendered by the Department shall be reviewed only under and in accordance with the Administrative Review Law. (c) For withholding of winnings, the State gaming licensee shall be entitled to an administrative fee not to exceed the lesser of 4% of the total amount of cash winnings paid to the gambling winner or $150. (d) In no event may the total amount withheld from the cash payout, including the administrative fee, exceed the total cash winnings claimed by the obligor. If the cash payout claimed is greater than the amount sufficient to satisfy the obligor's delinquent child support payments, the State gaming licensee shall pay the obligor the remaining balance of the payout, less the administrative fee authorized by subsection (c) of this Section, at the time it is claimed. (e) A State gaming licensee who in good faith complies with the requirements of this Section shall not be liable to the gaming winner or any other individual or entity.
(Source: P.A. 101-31, eff. 6-28-19.) |
(305 ILCS 5/10-18) (from Ch. 23, par. 10-18)
Sec. 10-18.
Recoveries-Deductibility of Direct Relatives' Support Payment.)
In any actions for the recovery of the financial aid, including actions
for the enforcement of estate and lien claims, amounts contributed by
responsible relatives either voluntarily or by court or administrative order
and paid to the
Illinois Department or to a local governmental unit shall be deducted from
the claim of the State or the governmental unit.
(Source: P.A. 79-474.)
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(305 ILCS 5/10-19) (from Ch. 23, par. 10-19)
Sec. 10-19. Support Payments Ordered Under Other Laws; where
deposited.
The Illinois Department and local governmental units are
authorized to receive payments directed by court order for the support
of recipients, as provided in the following Acts:
1. "Non-Support of Spouse and Children Act", approved | ||
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1.5. The Non-Support Punishment Act,
2. "Illinois Marriage and Dissolution of Marriage | ||
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3. The Illinois Parentage Act, as amended,
3.5. The Illinois Parentage Act of 2015, 4. "Revised Uniform Reciprocal Enforcement of Support | ||
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5. The Juvenile Court Act or the Juvenile Court Act | ||
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6. The "Unified Code of Corrections", approved July | ||
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7. Part 7 of Article XII of the Code of Civil | ||
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8. Part 8 of Article XII of the Code of Civil | ||
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9. Other laws which may provide by judicial order for | ||
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Payments under this Section to the Illinois Department pursuant to the Child
Support Enforcement Program established by Title IV-D of the Social Security
Act shall be paid into the Child Support Enforcement Trust Fund. All
payments under this Section to the Illinois Department of Human Services
shall be deposited in the DHS Recoveries Trust Fund.
Disbursements from these funds shall be as provided in Sections 12-9.1 and
12-10.2 of this Code. Payments received by a local governmental
unit shall be deposited in that unit's General Assistance Fund.
To the extent the provisions of this Section are inconsistent with the
requirements pertaining to the State Disbursement Unit under Sections 10-10.4
and 10-26 of this Code, the requirements pertaining to the State Disbursement
Unit shall apply.
(Source: P.A. 99-85, eff. 1-1-16.)
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(305 ILCS 5/10-20) (from Ch. 23, par. 10-20)
Sec. 10-20.
(Repealed).
(Source: P.A. 92-84, eff. 7-1-02. Repealed internally, eff. 7-1-02.)
|
(305 ILCS 5/10-21) (from Ch. 23, par. 10-21)
Sec. 10-21.
(Repealed).
(Source: P.A. 92-84, eff. 7-1-02. Repealed internally, eff. 7-1-02.)
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(305 ILCS 5/10-22) (from Ch. 23, par. 10-22)
Sec. 10-22.
(Repealed).
(Source: P.A. 87-1172. Repealed by P.A. 90-790, eff. 8-14-98.)
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(305 ILCS 5/10-23)
Sec. 10-23.
Employer obligations.
If a parent is required by a court or
administrative order for support to provide coverage for a child's health care
expenses and if that coverage is available to the parent through an employer
who does business in this State, the employer must do all of the
following upon receipt of a copy of the order of support or order for
withholding:
(1) The employer shall, upon the parent's request, | ||
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(2) If the parent has health care coverage through | ||
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(3) The employer may not eliminate any child from the | ||
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(A) The court or administrative order is no | ||
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(B) The child is or will be included in a | ||
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The employer may eliminate a child from a parent's | ||
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(Source: P.A. 89-183, eff. 1-1-96.)
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(305 ILCS 5/10-24)
Sec. 10-24.
Definitions.
In this Section through Section 10-24.50:
"Account" means a demand deposit account, checking or negotiable withdrawal
order account, savings account, time deposit account, or money market mutual
fund account.
"Financial institution" includes:
(1) a depository institution, which is any bank or | ||
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(2) an insured depository institution, which is any | ||
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(3) a federal depository institution, which is any | ||
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(4) a state depository institution, which is any | ||
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(5) a federal credit union, which is a cooperative | ||
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(6) a state chartered credit union which is organized | ||
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(7) any benefit association, insurance company, safe | ||
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"Financial record" has the meaning given to that term in Section 1101 of
the federal Right to Financial Privacy Act of 1978 (12 U.S.C. 3401).
(Source: P.A. 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-24.5)
Sec. 10-24.5.
Financial institutions data matches.
(a) The Illinois Department may design and implement a data match system
pursuant to which the Illinois Department shall enter into agreements with
financial institutions doing business in this State for the purpose of
identifying accounts as defined in Section 10-24
of responsible relatives who owe
past-due child support.
(b) Every
agreement entered into with a financial institution under this Section shall
provide, at the option of the financial institution, either (i) that the
financial institution shall compare data concerning
account holders, owners, or customers who maintain one or more accounts as
defined in Section 10-24 at the
financial institution with data concerning individuals identified by the
Illinois
Department as responsible relatives who owe past-due child
support and for each of whom the Illinois Department shall provide the name,
record address, and social security number or tax identification number, or
(ii) that the financial institution shall provide the
social
security number or tax identification number of the
account holders, owners, or customers who maintain one or more accounts as
defined in Section 10-24 at the
financial institution to the Illinois Department, which shall
compare that data with data concerning individuals identified
as responsible relatives who owe past-due
child support.
(c) Every agreement shall provide that the Illinois Department shall pay to
the financial institution providing or comparing the data a reasonable fee not
to exceed the
institution's actual cost of providing the data or performing the comparison.
(d) If the financial institution or Illinois Department determines that the
name and either social
security number or tax identification number of an individual identified by the
Illinois Department under subsection (b) match the name and either social
security number or tax identification number of the account holder, owner, or
customer
who maintains one or more accounts as defined in Section 10-24
at the financial institution,
then the financial institution
shall report the individual's name and either social security number or tax
identification number to the Illinois Department, for each calendar quarter in
which the individual is identified by the Illinois Department as a responsible
relative who owes past-due child support.
(Source: P.A. 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-24.30)
Sec. 10-24.30.
Types of accounts to be reported.
The reporting
requirements of Section 10-24.5 regarding accounts as defined in Section 10-24
apply to
individual accounts, joint accounts, and sole proprietorship accounts.
In the case of a joint account, the account holder or owner shall be deemed to
be the
primary account holder or owner established by the financial institution in
accordance
with federal 1099 reporting requirements.
(Source: P.A. 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-24.35)
Sec. 10-24.35. Accommodation of financial institutions. The Illinois
Department shall make a reasonable effort to accommodate
those financial institutions on which the requirements of this Article X
would impose a hardship. In the case of a non-automated financial
institution,
a paper copy including either social security numbers or tax identification
numbers is an acceptable format. In order to allow for data processing
implementation, no agreement shall become effective earlier than 90 days after
its execution.
(Source: P.A. 95-331, eff. 8-21-07.)
|
(305 ILCS 5/10-24.40)
Sec. 10-24.40. Financial institution's charges on account.
(a) If the Illinois Department requests a financial
institution to hold or encumber assets in an account as defined in Section
10-24, the financial institution at which the account as defined in Section
10-24 is maintained may
charge and collect its normally scheduled account activity fees to maintain the
account during the period of time the account assets are held or encumbered.
(b) If the Illinois Department takes any action to enforce
a lien or levy imposed on an account, as defined in Section 10-24, under
Section 10-25.5, the financial institution
at which the account is maintained may charge to the account a fee of up to $50
and shall deduct the amount of the fee from the account before
remitting any moneys from the account to the Illinois Department.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/10-24.45)
Sec. 10-24.45.
Confidentiality.
All information provided by a financial
institution under Sections 10-24 through 10-24.50 is confidential and may be
used only for the purpose of enforcing payment of child support.
The Illinois Department shall adopt rules to
safeguard any confidential information received from a financial institution.
(Source: P.A. 90-18, eff. 7-1-97.)
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(305 ILCS 5/10-24.50)
Sec. 10-24.50. Financial institution's freedom from liability. A
financial institution that provides information under Sections 10-24 through
10-24.50 shall not be liable to any account holder, owner, or other person in
any civil, criminal, or administrative action for any
of the following:
(1) Disclosing the required information to the | ||
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(2) Holding, encumbering, or surrendering any of an | ||
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(A) the Illinois Department under Sections 10-25 | ||
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(B) a person or entity acting on behalf of the | ||
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(3) Any other action taken or omission made in good | ||
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(Source: P.A. 100-201, eff. 8-18-17.)
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(305 ILCS 5/10-25)
Sec. 10-25. Administrative liens and levies on real property for
past-due child support and for fines against a payor who wilfully fails to withhold or pay over income pursuant to a properly served income withholding notice or otherwise fails to comply with any duties imposed by the Income Withholding for Support Act. (a) Notwithstanding any other State or local law to the contrary, the State shall have a lien on all legal and equitable interests of
responsible relatives in their real property
in the amount of past-due child support owing pursuant to an order
for child support entered under Sections 10-10 and 10-11 of this Code, or under
the Illinois Marriage and Dissolution of Marriage Act, the Non-Support of
Spouse and Children Act, the Non-Support Punishment Act, the Uniform
Interstate Family Support Act, the
Illinois Parentage Act of 1984, or the Illinois Parentage Act of 2015.
(a-5) The State shall have a lien on all legal and equitable interests of a payor, as that term is described in the Income Withholding for Support Act, in the payor's real property in the amount of any fine imposed by the Illinois Department pursuant to the Income Withholding for Support Act. (b) The Illinois Department shall provide by rule for notice to and an
opportunity to be heard by each responsible relative or payor affected, and any final
administrative decision rendered by the Illinois Department shall be reviewed
only under
and in accordance with the Administrative Review Law.
(c) When enforcing a lien under subsection (a) of this Section, the
Illinois Department shall have the authority to execute notices of
administrative liens and levies, which shall contain the name and address of
the responsible relative or payor, a legal description of the real property
to be levied, the fact that a lien
is being claimed for past-due child support or for the fines imposed on a payor pursuant to the Income Withholding for Support Act, and such other information as the
Illinois Department may by rule prescribe. The Illinois Department shall
record the notice of lien with the recorder or registrar of titles of
the county or counties in which the real estate is located.
(d) The State's lien under subsection (a) shall be
enforceable upon the recording or filing of a notice of lien with the recorder
or registrar of titles of the county or counties in which the real estate is
located. The lien shall be prior to any lien thereafter recorded or filed and
shall be notice to a subsequent purchaser, assignor, or encumbrancer of the
existence and nature of the lien. The lien shall be inferior to the lien of
general taxes, special assessment, and special taxes heretofore or hereafter
levied by any political subdivision or municipal corporation of the State.
In the event that title to the land to be affected by the notice of lien is
registered under the Registered Titles (Torrens) Act, the notice shall be filed
in the office of the registrar of titles as a memorial or charge upon each
folium of the register of titles affected by the notice; but the State shall
not have a preference over the rights of any bona fide purchaser, mortgagee,
judgment creditor, or other lien holders registered prior to the registration
of the notice.
(e) The recorder or registrar of titles of each county shall procure
a file labeled "Child Support Lien Notices" and an index book labeled "Child
Support Lien Notices". When notice of any lien is presented to the recorder or
registrar of titles for filing,
the recorder or registrar of titles shall file it in numerical order in the
file and shall enter it
alphabetically in the index. The entry shall show the name and last known
address of the person or payor named in the notice, the serial number of the notice, the
date and hour of filing, and the amount of child support or the amount of the fine imposed on the payor due at the time when
the lien is filed.
(f) The Illinois Department shall not be required to furnish bond or make a
deposit for or pay any costs or fees of any court or officer thereof in any
legal proceeding involving the lien.
(g) To protect the lien of the State for past-due child support and for any fine imposed against a payor, the
Illinois Department may, from funds that are available for that purpose, pay
or provide for the payment of necessary or essential repairs, purchase tax
certificates, pay balances due on land contracts, or pay or cause to be
satisfied any prior liens on the property to which the lien hereunder applies.
(h) A lien on real property under this Section shall be released
pursuant
to Section 12-101 of the Code of Civil Procedure.
(i) The Illinois Department, acting in behalf of the
State, may foreclose the lien in a judicial proceeding to the same extent and
in the same manner as in the enforcement of other liens. The process,
practice, and procedure for the foreclosure shall be the same as provided in
the Code of Civil Procedure.
(Source: P.A. 99-85, eff. 1-1-16; 99-157, eff. 7-1-17; 99-642, eff. 7-28-16.) |
(305 ILCS 5/10-25.5)
Sec. 10-25.5. Administrative liens and levies on personal property for
past-due child support and for fines against a payor who wilfully fails to withhold or pay over income pursuant to a properly served income withholding notice or otherwise fails to comply with any duties imposed by the Income Withholding for Support Act. (a) Notwithstanding any other State or local law to the contrary, the State shall have a lien on all legal and equitable interests of
responsible relatives in their personal property, including any account in a
financial institution as defined
in Section 10-24, or in the case of an insurance company or benefit association
only in accounts as defined in Section 10-24, in the amount of past-due child
support owing pursuant to an order
for child support entered under Sections 10-10 and 10-11 of this Code, or under
the Illinois Marriage and Dissolution of Marriage Act, the Non-Support of
Spouse and Children Act, the Non-Support Punishment Act, the Uniform
Interstate Family Support Act, the
Illinois Parentage Act of 1984, or the Illinois Parentage Act of 2015.
(a-5) The State shall have a lien on all legal and equitable interests of a payor, as that term is described in the Income Withholding for Support Act, in the payor's personal property in the amount of any fine imposed by the Illinois Department pursuant to the Income Withholding for Support Act. (b) The Illinois Department shall provide by rule for notice to and an
opportunity to be heard by each responsible relative or payor affected, and any final
administrative decision rendered by the Illinois Department shall be reviewed
only under
and in accordance with the Administrative Review Law.
(c) When enforcing a lien under subsection (a) of this Section, the
Illinois Department shall have the authority to execute notices of
administrative liens and levies, which shall contain the name and address of
the responsible relative or payor, a description of the property
to be levied, the fact that a lien
is being claimed for past-due child support, and such other information as the
Illinois Department may by rule prescribe. The Illinois Department may
serve the notice of lien or levy upon any financial institution where
the accounts as defined in Section 10-24 of the responsible relative may be
held, for encumbrance or surrender of the accounts as defined in Section 10-24
by the financial institution.
(d) The Illinois Department shall enforce its lien against the responsible
relative's or payor's personal property, other than accounts as defined in Section 10-24
in financial institutions,
and
levy upon such personal property in the manner provided for enforcement of
judgments contained in Article XII of the Code of Civil Procedure.
(e) The Illinois Department shall not be required to furnish bond or make a
deposit for or pay any costs or fees of any court or officer thereof in any
legal proceeding involving the lien.
(f) To protect the lien of the State for past-due child support and for any fine imposed on a payor, the
Illinois Department may, from funds that are available for that purpose, pay
or provide for the payment of necessary or essential repairs, purchase tax
certificates, or pay or cause to be
satisfied any prior liens on the property to which the lien hereunder applies.
(g) A lien on personal property under this Section shall be released
in the manner provided under Article XII
of the Code of Civil Procedure.
Notwithstanding the foregoing, a lien under this Section on accounts as defined
in Section 10-24 shall expire upon the passage of 120 days from the date of
issuance of the Notice of Lien or Levy by the Illinois Department. However,
the lien
shall remain in effect during the pendency of any appeal or protest.
(h) A lien created under this Section is subordinate to any prior lien of
the financial institution or any prior lien holder or any prior right of
set-off that the financial institution may have against the assets, or in the
case of an insurance company or benefit association only in the accounts as
defined in Section 10-24.
(i) A financial institution has no obligation under this Section to hold,
encumber, or surrender the assets, or in the case of an insurance company or
benefit association only the accounts as defined in Section 10-24, until the
financial
institution has been properly served with a subpoena, summons, warrant,
court or administrative order, or administrative lien and levy requiring that
action.
(Source: P.A. 99-85, eff. 1-1-16; 99-157, eff. 7-1-17; 99-642, eff. 7-28-16.) |
(305 ILCS 5/10-26)
Sec. 10-26.
State Disbursement Unit.
(a) Effective October 1, 1999 the Illinois Department shall establish a
State Disbursement Unit in accordance with the requirements of Title IV-D of
the Social Security Act. The Illinois Department shall enter into an agreement
with a State or local governmental unit or private entity to perform the
functions of the State Disbursement Unit as set forth in this Section. The
State Disbursement Unit shall collect and disburse support payments made under
court and administrative support orders:
(1) being enforced in cases in which child and spouse | ||
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(2) in all cases in which child and spouse support | ||
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(a-2) The contract entered into by the Illinois Department with a
public or
private entity or an individual for the operation of the State
Disbursement
Unit is subject to competitive bidding. In addition, the contract is subject
to Section
10-26.2 of this
Code. As used in this subsection (a-2), "contract" has the same meaning as in
the Illinois
Procurement Code.
(a-5) If the State Disbursement Unit receives a support payment that was
not appropriately made to the Unit under this Section, the Unit shall
immediately return the payment to the sender, including, if possible,
instructions detailing where to send the support payments.
(b) All payments received by the State Disbursement Unit:
(1) shall be deposited into an account obtained by | ||
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(2) distributed and disbursed by the State | ||
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(c) All support payments assigned to the Illinois Department under Article X
of this Code and rules promulgated by the Illinois Department that are
disbursed to the Illinois Department by the State Disbursement Unit shall be
paid into the Child Support Enforcement Trust Fund.
(d) If the agreement with the State or local governmental unit or private
entity provided for in this Section is not in effect for any reason, the
Department shall perform the functions of the State Disbursement Unit as set
forth in this Section for a maximum of 12 months before July 1, 2001, and for
a
maximum of 24 months after June 30, 2001. If the Illinois Department is
performing the functions of the State Disbursement Unit on July 1, 2001, then
the Illinois Department shall make an award on or before December 31, 2002, to
a State or local government unit or private entity to perform the functions of
the State Disbursement Unit.
Payments received by the Illinois Department in performance of the duties
of the State
Disbursement Unit shall be deposited into the State Disbursement Unit Revolving
Fund established under Section 12-8.1.
Nothing in this Section shall prohibit the Illinois Department from holding
the State Disbursement Unit Revolving Fund after June 30, 2003.
(e) By February 1, 2000, the Illinois Department shall conduct at least 4
regional training and educational seminars to educate the clerks of the circuit
court on the general operation of the State Disbursement Unit, the role of the
State Disbursement Unit, and the role of the clerks of the circuit court in the
collection and distribution of child support payments.
(f) By March 1, 2000, the Illinois Department shall conduct at least 4
regional educational and training seminars to educate payors, as defined
in the Income Withholding for Support Act, on the general operation of the
State Disbursement Unit, the role of the State Disbursement Unit, and the
distribution of income withholding payments pursuant to this Section and the
Income Withholding for Support Act.
(Source: P.A. 92-44, eff. 7-1-01; 93-20, eff. 6-20-03.)
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(305 ILCS 5/10-26.2)
Sec. 10-26.2.
Contracts concerning the operation of the State Disbursement
Unit.
(a) In this Section:
"Contract" has the same meaning as in the Illinois Procurement Code.
"SDU contractor" means any public or private entity or individual with whom
the
Illinois Department enters into a contract in connection with the operation of
the State
Disbursement Unit.
(b) The contract entered into by the Illinois Department with a public or
private
entity or an individual in connection with the operation of the State
Disbursement Unit
must contain, at a minimum, the provisions set forth in this Section.
(c) The contract must include standards and procedures
to ensure that the data
relied on
by the State Disbursement Unit in performing its functions is accurate so that
the State
Disbursement Unit will be able to effectively administer the collection and
disbursement
of support payments.
(d) The contract must contain provisions to ensure that all clerks of the
circuit
court have access to
non-custodial
parents' support payment information in the possession of the State
Disbursement Unit.
(e) The contract must contain provisions to ensure that notices to employers
in
connection with the collection of support are clear and consistent and that the
SDU
contractor will promptly inform an employer about any problems and any
necessary
changes in connection with the collection of support.
(f) The contract must contain appropriate management controls to ensure that
(i)
all of the SDU contractor's actions in performing the functions of the State
Disbursement
Unit are reasonably planned, timely implemented, and adequately controlled and
(ii) all
reports that are necessary to provide the Illinois Department with the
information
necessary to effectively monitor the quality and accuracy of the SDU
contractor's actions
in performing the functions of the State Disbursement Unit are timely filed.
(g) The contract must contain provisions specifying standards with respect
to the level of performance expected of the SDU contractor. The contract may
include provisions for incentives and penalties in connection with the SDU
contractor's performance.
(h) The contract must contain provisions projecting the number of active
support collection and disbursement cases to be handled by the State
Disbursement Unit and estimating the number of support disbursement
transactions to be handled each year.
(i) The contract must contain provisions requiring
compliance with all
applicable federal
requirements concerning disbursement of support.
The contract must also contain provisions for the Illinois Department's
regular, periodic
review of reports on disbursement performance.
(j) The contract must contain provisions requiring the SDU contractor to
submit
to the Illinois Department, within 45 days after the end of each State fiscal
year, a
completed American Institute of Certified Public Accountants Statement on
Auditing
Standards Number 88 (SAS 88) or its successor for the purpose of enabling the
Illinois
Department to
appropriately monitor the State Disbursement Unit's performance as a service
organization and to enable the Auditor General, as the external auditor of the
State
Disbursement Unit, to ensure that appropriate controls are present.
(k) The contract must contain provisions requiring the Illinois Department
and the
SDU contractor to examine the causes of untimely disbursement of support
payments and
inappropriate cost recovery and to take prompt action to ensure the timely and
accurate
disbursement of support payments. The contract must also contain provisions
for the
final disposition of support payments that cannot be processed by
the State
Disbursement Unit within 2 business days.
(l) The contract must contain provisions to ensure that neither the Illinois
Department nor the SDU contractor uses moneys collected and held in trust for
the
payment of support for any purpose other than that for which the moneys were
collected.
(m) The contract must contain provisions requiring the Illinois Department
to audit
the disbursement of all emergency support payments and report to the General
Assembly
the results of the audit, including, without limitation, the number of
emergency support
payment checks issued by the State Disbursement Unit, the amount of repayments
received from recipients of those checks, and amounts for which the Illinois
Department did not seek repayment.
(Source: P.A. 92-44, eff. 7-1-01.)
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(305 ILCS 5/10-26.5)
Sec. 10-26.5.
Delayed payment from State Disbursement Unit.
(a) In this Section, "adversely affected recipient of support" means a person
who meets
all of the following criteria:
(1) The person is entitled to disbursement of a child | ||
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(2) The person either (i) does not receive from the | ||
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(3) As a result of the nonreceipt of the disbursement | ||
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(b) Upon the request of an adversely affected recipient of support, the
Illinois Department shall send a letter to the recipient
verifying the delayed or undisbursed child support payment. The recipient may
submit that letter to the appropriate credit reporting
agency for placement in the recipient's credit file.
(c) The Illinois Department shall adopt rules necessary to implement this
Section.
(Source: P.A. 91-793, eff. 6-9-00.)
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(305 ILCS 5/10-27)
Sec. 10-27. State Case Registry.
(a) The Illinois Department shall establish an automated State Case
Registry to
contain records concerning child support orders for parties receiving child
support enforcement services under this Article X, and for all child support
orders entered or modified on or after October 1, 1998. The State Case
Registry shall include (i) the information filed with the Illinois Department,
or filed with the clerk of the circuit court and provided to the Illinois
Department, under the provisions of Sections 10-10.5 and 10-11.2 of this Code,
Section 505.3 of the Illinois Marriage and Dissolution of Marriage Act, Section
30 of the Non-Support Punishment Act, Section 803 of the Illinois Parentage Act of 2015, and Section 14.1 of the Illinois
Parentage Act of 1984, and (ii) any other information required under Title IV,
Part D of the Social Security Act or by the federal Department of Health and
Human Services.
(b) (Blank).
(c) The Illinois Department shall maintain the following payment information
on child support orders for parties receiving child support
enforcement services
under
this Article X:
(1) the amount of monthly or other periodic support | ||
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(2) any amounts described in subdivision (1) of | ||
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(3) the distribution of the collected amounts; and
(4) the amount of any lien imposed with respect to | ||
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(d) The Illinois Department shall establish, update, maintain, and monitor
case records in the Registry of parties receiving child support
enforcement services under this Article X, on the bases of:
(1) information on administrative actions and | ||
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(2) information obtained from comparison with | ||
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(3) information on support collections and | ||
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(4) any other relevant information.
(e) The Illinois Department shall use the automated State Case Registry to
share and compare information with, and receive information from, other data
bases and information comparison services in order to obtain (or provide)
information necessary to enable the Illinois Department (or the federal
Department of Health and Human Services or other State or federal agencies) to
carry out the requirements of the child support enforcement program established
under Title IV, Part D of the Social Security Act. Such information comparison
activities shall include the following:
(1) Furnishing to the Federal Case Registry of Child | ||
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(2) Exchanging information with the Federal Parent | ||
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(3) Exchanging information with State agencies (of | ||
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(4) Exchanging information with other agencies of | ||
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(5) Disclosing information to any other entities as | ||
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(f) The Illinois Department shall adopt rules establishing safeguards,
applicable to all confidential information included in the State Case Registry,
that are designed to protect the privacy rights of persons concerning whom
information is on record in the State Case Registry. Such safeguards shall
include,
but not be limited to the following:
(1) Prohibitions against the release of information | ||
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(2) Prohibitions against the release of information | ||
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(3) Prohibitions against the release of information | ||
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(Source: P.A. 99-85, eff. 1-1-16.)
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(305 ILCS 5/10-28) Sec. 10-28. Notice of child support enforcement services. The Illinois Department may provide notice at any time to the parties to a judicial action filed under this Code, or under any other law providing for support of a spouse or dependent child, that child support enforcement services are being provided by the Illinois Department under this Article X. The notice shall be sent by regular mail to the party's last known address on file with the clerk of the court or the State Case Registry established under Section 10-27. After notice is provided pursuant to this Section, the Illinois Department shall be entitled, as if it were a party, to notice of any further proceedings brought in the case. The Illinois Department shall provide the clerk of the court with copies of the notices sent to the parties. The clerk shall file the copies in the court file.
(Source: P.A. 94-88, eff. 1-1-06.) |
(305 ILCS 5/Art. XI heading) ARTICLE XI.
GENERAL PROVISIONS PERTAINING
TO RIGHTS AND RESPONSIBILITIES OF
APPLICANTS AND RECIPIENTS
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(305 ILCS 5/11-1) (from Ch. 23, par. 11-1)
Sec. 11-1.
No discrimination).
There shall be no discrimination or denial
of financial aid and social services on account of the race, religion, color,
national origin, sex, marital status, or political affiliation of any
applicant or recipient. This paragraph shall not prevent the Department from
treating individuals differently as a result of the rights and responsibilities
that arise under law from marital status.
Participation in any marriage promotion or family formation activity is
voluntary.
Non-participation shall not affect any person's eligibility for or receipt of
financial aid or
social services in any program under this Code.
Where financial aid or social services are granted to certain classes of
persons under a program for which federal funds are available, nothing in
this Section shall require granting of financial aid or social services
to other persons where federal funds would not be available as to those other
persons.
(Source: P.A. 93-598, eff. 8-26-03.)
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(305 ILCS 5/11-2) (from Ch. 23, par. 11-2)
Sec. 11-2.
Conduct
of administrative staff.
Every person administering any provision of this Code shall conduct
himself or herself with courtesy, consideration and respect toward all
applicants and
recipients and perform duties in such manner as to secure for every
applicant and recipient the aid and services to which the person
may be entitled.
Any applicant or recipient who feels he or she has not been treated properly
by administrative staff or the Department in regard to the aforementioned
conduct provisions shall be afforded the right to complain to the Department
about such treatment. The Department shall advise applicants and recipients
of this right through informational brochures and publicly posted information.
Such complaints shall be treated confidentially and the Department and its
employees shall not otherwise discriminate against any applicant or recipient
because such individual complains about the conduct of Department staff.
(Source: P.A. 82-555.)
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(305 ILCS 5/11-2.1) (from Ch. 23, par. 11-2.1)
Sec. 11-2.1.
No private business and vocational school, as defined in
the Private Business and Vocational Schools Act of 2012,
may solicit an
applicant or recipient within a public aid office or within 100 feet of a
public aid office, for the purpose of enrolling the applicant or recipient
in a work or training program, without the express written consent of the
Illinois Department.
Any person violating this Section shall be guilty of a Class A misdemeanor.
"Public aid office" for the purpose of this Section includes any
business office of the Department where a person may apply for or receive
benefits or services under this Code, the building in which such office is
located, and any parking area connected to such office that is owned or
leased by the State for the benefit of the Department for use by personnel
of the Department or by applicants or recipients.
(Source: P.A. 97-650, eff. 2-1-12.)
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(305 ILCS 5/11-3) (from Ch. 23, par. 11-3)
Sec. 11-3. Assignment and attachment of aid prohibited. Except as provided
below in this
Section and in Section 11-3.3, all financial aid given under
Articles III, IV, V, and VI and money payments for child care
services
provided by a child care provider under Articles
IX
and IXA shall not be subject to
assignment,
sale,
attachment, garnishment, or otherwise. Provided, however, that a medical
vendor may use his right to receive vendor payments as collateral for loans
from financial institutions so long as such arrangements do not constitute
any activity prohibited under Section 1902(a)(32) of the Social Security
Act and regulations promulgated thereunder, or any other applicable laws or
regulations. Provided further, however, that a medical or other vendor or a
service provider may assign, reassign, sell, pledge or grant a security
interest in any such financial aid, vendor payments or money payments or
grants which he has a right to receive to the Illinois
Finance Authority, in connection with any financing program undertaken by
the Illinois Finance Authority. Each Authority may utilize a
trustee or agent to accept, accomplish, effectuate or realize upon any such
assignment, reassignment, sale, pledge or grant on that Authority's behalf.
Provided further, however, that nothing herein shall prevent the Illinois
Department from collecting any assessment, fee, interest or penalty due under
Article V-A, V-B, V-C, or V-E by withholding financial aid as payment of such
assessment, fee, interest, or penalty. Any alienation in contravention of this
statute does not diminish and does not affect the validity, legality or
enforceability of any underlying obligations for which such alienation may
have been made as collateral between the parties to the alienation. This
amendatory Act shall be retroactive in application and shall pertain to
obligations existing prior to its enactment.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/11-3.1) (from Ch. 23, par. 11-3.1)
Sec. 11-3.1. Any recipient of financial aid which is payable to the
recipient at regular intervals may elect to have the aid deposited, and the
Illinois Department of Human Services is authorized to deposit the aid,
directly in the
recipient's savings account or checking account or in any electronic
benefits transfer account or accounts in a financial institution approved
by the Illinois Department of Human Services and in accordance with the rules
and regulations
of the Department of Human Services. The Illinois Department of Human Services
and any electronic benefits
transfer financial institutions or contractor shall encourage financial
institutions to provide checking account and savings account services to
recipients of public aid.
Any recipient of financial aid or benefits distributed by means other
than electronic benefits transfer under Articles III, IV, and VI of this
Code may elect to receive the aid by means of direct deposit transmittals
to his or her account maintained at a bank, savings and loan association,
or credit union or by means of electronic benefits transfer in a financial
institution approved by the Illinois Department of Human Services and in accordance with
rules and regulations of the Illinois Department of Human Services. The Illinois Department of Human Services
may distribute financial aid or food stamp benefits by means of electronic
benefits transfer and may require recipients to receive financial aid or
food stamp benefits by means of electronic benefits transfer, provided that
any electronic benefits transfer made under this Section shall be
accomplished in compliance with the Electronic Fund Transfer Act and any relevant rules promulgated thereunder. The Illinois
Department of Human Services may provide for a method of compensation for services in
accordance with the rules and regulations of the Illinois Department of Human Services, the
United States Department of Agriculture, the United States Department of
Health and Human Services, and the State Comptroller and the State
Treasurer. The Illinois Department of Human Services shall require a
convenient density of
distribution points for recipients of public aid to have adequate options
to access aid held in an electronic benefits transfer account. No fee may
be charged to recipients for reasonable access to public aid benefits held
in such an account. Deposits into a financial institution for electronic
benefits transfer accounts shall be subject to community reinvestment and
to serving public benefits recipients pursuant to relevant criteria of the
State Treasurer, Comptroller, and the Illinois Department of Human
Services.
The Electronic Benefits Transfer Fund is hereby created for the purpose of
electronically disbursing public aid benefits.
The electronic benefits transfer contractor shall inform the Department of
Human Services
whenever it has distributed financial aid to individuals by means of electronic
benefits transfer. The Illinois Department of Human Services shall determine
the amount to be
reimbursed to the contractor and shall direct the State Treasurer to transfer
this
portion of the amount previously vouchered by the Department of Human Services
and approved by
the Comptroller pursuant to Section 9.05(c) of the State Comptroller Act to the
contractor from the Electronic Benefits Transfer Fund created
under Section 9.05(b) of the State Comptroller Act in accordance with the rules
and regulations of the Illinois Department of Human Services, the United
States Department of
Agriculture, the United States Department of Health and Human Services, the
State Comptroller, and the State Treasurer.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/11-3.2) (from Ch. 23, par. 11-3.2)
Sec. 11-3.2.
Upon the request of a penal or correctional facility,
the Illinois Department shall cooperate in providing informational material
and application forms concerning financial aid or social services under
this Act to the facility and in providing an interview with the appropriate
Public Aid office for persons incarcerated in such facility upon their
release from the facility.
In consideration of any application for financial aid or social
services of persons released from a penal or correctional institution,
a permanent address shall not be required to establish residence in the
determination of eligibility. Other requirements necessary to establish
eligibility for assistance under this code shall apply.
(Source: P.A. 82-497.)
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(305 ILCS 5/11-3.3) (from Ch. 23, par. 11-3.3)
Sec. 11-3.3. Payment to provider or governmental agency or entity.
Payments under this Code shall be made to the provider, except that the
Department may issue or may agree to issue the payment directly to
the Illinois
Finance
Authority or any other governmental agency or entity, including any bond
trustee for that agency or entity, to whom the provider has assigned,
reassigned, sold, pledged or granted a security interest in the payments
that the provider has a right to receive, provided that the issuance or
agreement to issue is not prohibited under Section 1902(a)(32) of the Social
Security Act.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/11-4) (from Ch. 23, par. 11-4)
Sec. 11-4.
Applications; assistance in making applications.
An application for public assistance shall be deemed an application for
all such benefits to which any person may be entitled except to the
extent that the applicant expressly declines
in writing to apply for particular benefits. The Illinois Department shall
provide information in writing about all benefits provided under this Code
to any person seeking public assistance.
The Illinois Department shall also provide information in writing and orally
to all applicants about an election to have financial aid deposited directly in
a recipient's savings account or checking account or in any electronic benefits
account or accounts as provided in Section 11-3.1, to the extent that those
elections are actually available, including information on any programs
administered by the State Treasurer to facilitate or encourage the distribution
of financial aid by direct deposit or electronic benefits transfer.
The Illinois Department shall
determine the applicant's eligibility for cash assistance, medical
assistance and food stamps unless the applicant expressly declines in
writing to apply for particular benefits.
The Illinois Department shall adopt policies and procedures to facilitate
timely changes between programs that result from changes in categorical
eligibility factors.
The County departments, local governmental units and the Illinois
Department shall
assist applicants for public assistance to properly complete their
applications. Such assistance shall include, but not be limited to, assistance
in securing
evidence in support of their eligibility.
(Source: P.A. 88-232.)
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(305 ILCS 5/11-4.1) Sec. 11-4.1. Medical providers assisting with applications for medical assistance. A provider enrolled to provide medical assistance services may, upon the request of an individual, accompany, represent, and assist the individual in applying for medical assistance under Article V of this Code. If an individual is unable to request such assistance due to incapacity or mental incompetence and has no other representative willing or able to assist in the application process, a facility licensed under the Nursing Home Care Act, the ID/DD Community Care Act, or the MC/DD Act or certified under this Code is authorized to assist the individual in applying for long-term care services. Subject to the provisions of the Free Healthcare Benefits Application Assistance Act, nothing in this Section shall be construed as prohibiting any individual or entity from assisting another individual in applying for medical assistance under Article V of this Code.
(Source: P.A. 99-180, eff. 7-29-15.) |
(305 ILCS 5/11-4.2) Sec. 11-4.2. Application assistance for enrolling individuals in the medical assistance program. (a) The Department shall have procedures to allow application agents to assist in enrolling individuals in the medical assistance program. As used in this Section, "application agent" means an organization or individual, such as a licensed health care provider, school, youth service agency, employer, labor union, local chamber of commerce, community-based organization, or other organization, approved by the Department to assist in enrolling individuals in the medical assistance program. (b) At the Department's discretion, technical assistance payments may be made available for approved applications facilitated by an application agent. The Department shall permit day and temporary labor service agencies, as defined in the Day and Temporary Labor Services Act, doing business in Illinois to enroll as unpaid application agents. As established in the Free Healthcare Benefits Application Assistance Act, it shall be unlawful for any person to charge another person or family for assisting in completing and submitting an application for enrollment in the medical assistance program. (c) Existing enrollment agreements or contracts for all application agents, technical assistance payments, and outreach grants that were authorized under Section 22 of the Children's Health Insurance Program Act and Sections 25 and 30 of the Covering ALL KIDS Health Insurance Act prior to those Acts becoming inoperative shall continue to be authorized under this Section per the terms of the agreement or contract until modified, amended, or terminated.
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/11-5) (from Ch. 23, par. 11-5)
Sec. 11-5. Investigation of applications.
The County Department or local governmental unit shall promptly, upon
receipt of an application, make the necessary investigation, as
prescribed by rule of the Illinois Department, for determining the
eligibility of the applicant for aid.
A report of every investigation shall be made in writing and become a
part of the record in each case.
The Illinois Department may by
rule prescribe the circumstances under which information furnished by
applicants in respect to their eligibility may be presumed prima facie
correct, subject to all civil and criminal penalties and recoveries
provided in this Code if the additional investigation establishes that
the applicant made false statements or was otherwise ineligible for
aid.
(Source: P.A. 93-632, eff. 2-1-04.)
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(305 ILCS 5/11-5.1) Sec. 11-5.1. Eligibility verification. Notwithstanding any other provision of this Code, with respect to applications for medical assistance provided under Article V of this Code, eligibility shall be determined in a manner that ensures program integrity and complies with federal laws and regulations while minimizing unnecessary barriers to enrollment. To this end, as soon as practicable, and unless the Department receives written denial from the federal government, this Section shall be implemented: (a) The Department of Healthcare and Family Services or its designees shall: (1) By no later than July 1, 2011, require | ||
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(2) By no later than October 1, 2011, require | ||
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(3) By no later than July 1, 2011, require | ||
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The Department, with federal approval, may choose to adopt continuous financial eligibility for a full 12 months for adults on Medicaid. (b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants or current recipients of health benefits under the Program. Data shall be requested or provided for any new applicant or current recipient only insofar as that individual's circumstances are relevant to that individual's or another individual's eligibility. (c) Within 90 days of the effective date of this amendatory Act of the 96th General Assembly, the Department of Healthcare and Family Services shall send notice to current recipients informing them of the changes regarding their eligibility verification.
(d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall compile on a monthly basis data on eligibility redeterminations of beneficiaries of medical assistance provided under Article V of this Code. In addition to the
other data required under this subsection, the Department
shall compile on a monthly basis data on the percentage of
beneficiaries whose eligibility is renewed through ex parte
redeterminations as described in subsection (b) of Section
5-1.6 of this Code, subject to federal approval of the changes
made in subsection (b) of Section 5-1.6 by this amendatory Act
of the 102nd General Assembly. This data shall be posted on the Department's website, and data from prior months shall be retained and available on the Department's website. The data compiled and reported shall include the following: (1) The total number of redetermination decisions | ||
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(2) A breakdown of enrollee language preference for | ||
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(3) The percentage of cancellation decisions made in | ||
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(A) The beneficiary's ineligibility due to excess | ||
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(B) The beneficiary's ineligibility due to not | ||
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(C) The beneficiary's ineligibility due to being | ||
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(D) The beneficiary's request to cancel benefits. (E) The beneficiary's lack of response after | ||
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(F) The beneficiary's lack of response to a | ||
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(G) Other reasons tracked by the Department for | ||
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(4) If a vendor is utilized to provide services in | ||
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(5) Of the total number of benefit cancellations in a | ||
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(e) The Department shall conduct a complete review of the Medicaid redetermination process in order to identify changes that can increase the use of ex parte redetermination processing. This review shall be completed within 90 days after the effective date of this amendatory Act of the 101st General Assembly. Within 90 days of completion of the review, the Department shall seek written federal approval of policy changes the review recommended and implement once approved. The review shall specifically include, but not be limited to, use of ex parte redeterminations of the following populations: (1) Recipients of developmental disabilities | ||
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(2) Recipients of benefits under the State's Aid to | ||
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(3) Recipients of Medicaid long-term care services | ||
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(4) All Modified Adjusted Gross Income (MAGI) | ||
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(5) Populations with no verifiable income. (6) Self-employed people. The report shall also outline populations and circumstances in which an ex parte redetermination is not a recommended option. (f) The Department shall explore and implement, as practical and technologically possible, roles that stakeholders outside State agencies can play to assist in expediting eligibility determinations and redeterminations within 24 months after the effective date of this amendatory Act of the 101st General Assembly. Such practical roles to be explored to expedite the eligibility determination processes shall include the implementation of hospital presumptive eligibility, as authorized by the Patient Protection and Affordable Care Act. (g) The Department or its designee shall seek federal approval to enhance the reasonable compatibility standard from 5% to 10%. (h) Reporting. The Department of Healthcare and Family Services and the Department of Human Services shall publish quarterly reports on their progress in implementing policies and practices pursuant to this Section as modified by this amendatory Act of the 101st General Assembly. (1) The reports shall include, but not be limited to, | ||
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(A) Medical application processing, including a | ||
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(B) Medical redeterminations completed, | ||
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(C) A narrative discussion on issues identified | ||
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(2) Initial reports shall be issued within 90 days | ||
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(3) All reports shall be published on the | ||
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(i) It is the determination of the General Assembly that the Department must include seniors and persons with disabilities in ex parte renewals. It is the determination of the General Assembly that the Department must use its asset verification system to assist in the determination of whether an individual's coverage can be renewed using the ex parte process. If a State Plan amendment is required, the Department shall pursue such State Plan amendment by July 1, 2022. Within 60 days after receiving federal approval or guidance, the Department of Healthcare and Family Services and the Department of Human Services shall make necessary technical and rule changes to implement these changes to the redetermination process. (Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20; 102-1037, eff. 6-2-22.) |
(305 ILCS 5/11-5.2) Sec. 11-5.2. Income, Residency, and Identity Verification System. (a) The Department shall ensure that its proposed integrated eligibility system shall include the computerized functions of income, residency, and identity eligibility verification to verify eligibility, eliminate duplication of medical assistance, and deter fraud. Until the integrated eligibility system is operational, the Department may enter into a contract with the vendor selected pursuant to Section 11-5.3 as necessary to obtain the electronic data matching described in this Section. This contract shall be exempt from the Illinois Procurement Code pursuant to subsection (h) of Section 1-10 of that Code. (b) Prior to awarding medical assistance at application under Article V of this Code, the Department shall, to the extent such databases are available to the Department, conduct data matches using the name, date of birth, address, and Social Security Number of each applicant or recipient or responsible relative of an applicant or recipient against the following: (1) Income tax information. (2) Employer reports of income and unemployment | ||
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(3) Earned and unearned income, citizenship and | ||
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(4) Immigration status information maintained by the | ||
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(5) Wage reporting and similar information maintained | ||
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(6) Employment information maintained by the | ||
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(7) Employment information maintained by the United | ||
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(8) Veterans' benefits information maintained by the | ||
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(9) Residency information maintained by the Illinois | ||
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(10) A database which is substantially similar to or | ||
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(c) (Blank). (d) If a discrepancy results between information provided by an applicant, recipient, or responsible relative and information contained in one or more of the databases or information tools listed under subsection (b) of this Section or subsection (c) of Section 11-5.3 and that discrepancy calls into question the accuracy of information relevant to a condition of eligibility provided by the applicant, recipient, or responsible relative, the Department or its contractor shall review the applicant's or recipient's case using the following procedures: (1) If the information discovered under subsection | ||
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(2) If the information discovered results in the | ||
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(3) If the information discovered is insufficient to | ||
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(4) If the applicant or recipient does not respond to | ||
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(5) If an applicant or recipient responds to the | ||
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(6) Suspected cases of fraud shall be referred to the | ||
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(e) The Department shall adopt any rules necessary to implement this Section.
(Source: P.A. 97-689, eff. 6-14-12; 98-756, eff. 7-16-14.) |
(305 ILCS 5/11-5.3) Sec. 11-5.3. Procurement of vendor to verify eligibility for assistance under Article V. (a) No later than 60 days after the effective date of this amendatory Act of the 97th General Assembly, the Chief Procurement Officer for General Services, in consultation with the Department of Healthcare and Family Services, shall conduct and complete any procurement necessary to procure a vendor to verify eligibility for assistance under Article V of this Code. Such authority shall include procuring a vendor to assist the Chief Procurement Officer in conducting the procurement. The Chief Procurement Officer and the Department shall jointly negotiate final contract terms with a vendor selected by the Chief Procurement Officer. Within 30 days of selection of an eligibility verification vendor, the Department of Healthcare and Family Services shall enter into a contract with the selected vendor. The Department of Healthcare and Family Services and the Department of Human Services shall cooperate with and provide any information requested by the Chief Procurement Officer to conduct the procurement. (b) Notwithstanding any other provision of law, any procurement or contract necessary to comply with this Section shall be exempt from: (i) the Illinois Procurement Code pursuant to Section 1-10(h) of the Illinois Procurement Code, except that bidders shall comply with the disclosure requirement in Sections 50-10.5(a) through (d), 50-13, 50-35, and 50-37 of the Illinois Procurement Code and a vendor awarded a contract under this Section shall comply with Section 50-37 of the Illinois Procurement Code; (ii) any administrative rules of this State pertaining to procurement or contract formation; and (iii) any State or Department policies or procedures pertaining to procurement, contract formation, contract award, and Business Enterprise Program approval. (c) Upon becoming operational, the contractor shall conduct data matches using the name, date of birth, address, and Social Security Number of each applicant and recipient against public records to verify eligibility. The contractor, upon preliminary determination that an enrollee is eligible or ineligible, shall notify the Department, except that the contractor shall not make preliminary determinations regarding the eligibility of persons residing in long term care facilities whose income and resources were at or below the applicable financial eligibility standards at the time of their last review. Within 20 business days of such notification, the Department shall accept the recommendation or reject it with a stated reason. The Department shall retain final authority over eligibility determinations. The contractor shall keep a record of all preliminary determinations of ineligibility communicated to the Department. Within 30 days of the end of each calendar quarter, the Department and contractor shall file a joint report on a quarterly basis to the Governor, the Speaker of the House of Representatives, the Minority Leader of the House of Representatives, the Senate President, and the Senate Minority Leader. The report shall include, but shall not be limited to, monthly recommendations of preliminary determinations of eligibility or ineligibility communicated by the contractor, the actions taken on those preliminary determinations by the Department, and the stated reasons for those recommendations that the Department rejected. (d) An eligibility verification vendor contract shall be awarded for an initial 2-year period with up to a maximum of 2 one-year renewal options. Nothing in this Section shall compel the award of a contract to a vendor that fails to meet the needs of the Department. A contract with a vendor to assist in the procurement shall be awarded for a period of time not to exceed 6 months.
(e) The provisions of this Section shall be administered in compliance with federal law. (Source: P.A. 101-10, eff. 6-5-19; 101-209, eff. 8-5-19.) |
(305 ILCS 5/11-5.4) Sec. 11-5.4. Expedited long-term care eligibility determination and enrollment. (a) Establishment of the expedited long-term care eligibility determination and enrollment system shall be a joint venture of the Departments of Human Services and Healthcare and Family Services and the Department on Aging. (b) Streamlined application enrollment process; expedited eligibility process. The streamlined application and enrollment process must include, but need not be limited to, the following: (1) On or before July 1, 2019, a streamlined | ||
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(A) Minimize the burden on applicants by | ||
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(B) Integrate online data sources to simplify the | ||
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(C) Provide online prompts to alert the applicant | ||
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(D) Provide training and step-by-step written | ||
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(2) The State must expedite the eligibility process | ||
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(A) Full Medicaid benefits in the community for a | ||
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(B) No transfer of assets or resources during the | ||
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(C) Receives Supplemental Security Income | ||
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(D) For applicants or recipients with verified | ||
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(3) Subject to federal approval, the Department of | ||
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(4) The Department of Human Services must use the | ||
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(c) The Department of Human Services must adopt policies and procedures to improve communication between long-term care benefits central office personnel, applicants and their representatives, and facilities in which the applicants reside. Such policies and procedures must at a minimum permit applicants and their representatives and the facility in which the applicants reside to speak directly to an individual trained to take telephone inquiries and provide appropriate responses.
(d) Effective 30 days after the completion of 3 regionally based trainings, nursing facilities shall submit all applications for medical assistance online via the Application for Benefits Eligibility (ABE) website. This requirement shall extend to scanning and uploading with the online application any required additional forms such as the Long Term Care Facility Notification and the Additional Financial Information for Long Term Care Applicants as well as scanned copies of any supporting documentation. Long-term care facility admission documents must be submitted as required in Section 5-5 of this Code. No local Department of Human Services office shall refuse to accept an electronically filed application. No Department of Human Services office shall request submission of any document in hard copy. (e) Notwithstanding any other provision of this Code, the Department of Human Services and the Department of Healthcare and Family Services' Office of the Inspector General shall, upon request, allow an applicant additional time to submit information and documents needed as part of a review of available resources or resources transferred during the look-back period. The initial extension shall not exceed 30 days. A second extension of 30 days may be granted upon request. Any request for information issued by the State to an applicant shall include the following: an explanation of the information required and the date by which the information must be submitted; a statement that failure to respond in a timely manner can result in denial of the application; a statement that the applicant or the facility in the name of the applicant may seek an extension; and the name and contact information of a caseworker in case of questions. Any such request for information shall also be sent to the facility. In deciding whether to grant an extension, the Department of Human Services or the Department of Healthcare and Family Services' Office of the Inspector General shall take into account what is in the best interest of the applicant. The time limits for processing an application shall be tolled during the period of any extension granted under this subsection. (f) The Department of Human Services and the Department of Healthcare and Family Services must jointly compile data on pending applications, denials, appeals, and redeterminations into a monthly report, which shall be posted on each Department's website for the purposes of monitoring long-term care eligibility processing. The report must specify the number of applications and redeterminations pending long-term care eligibility determination and admission and the number of appeals of denials in the following categories: (A) Length of time applications, redeterminations, | ||
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(B) Percentage of applications and redeterminations | ||
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(C) Status of pending applications, denials, appeals, | ||
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(g) Beginning on July 1, 2017, the Auditor General shall report every 3 years to the General Assembly on the performance and compliance of the Department of Healthcare and Family Services, the Department of Human Services, and the Department on Aging in meeting the requirements of this Section and the federal requirements concerning eligibility determinations for Medicaid long-term care services and supports, and shall report any issues or deficiencies and make recommendations. The Auditor General shall, at a minimum, review, consider, and evaluate the following: (1) compliance with federal regulations on furnishing | ||
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(2) compliance with federal regulations on the timely | ||
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(3) the accuracy and completeness of the report | ||
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(4) the efficacy and efficiency of the task-based | ||
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(5) any issues affecting eligibility determinations | ||
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The Auditor General's report shall include any and all other areas or issues which are identified through an annual review. Paragraphs (1) through (5) of this subsection shall not be construed to limit the scope of the annual review and the Auditor General's authority to thoroughly and completely evaluate any and all processes, policies, and procedures concerning compliance with federal and State law requirements on eligibility determinations for Medicaid long-term care services and supports. (h) The Department of Healthcare and Family Services shall adopt any rules necessary to administer and enforce any provision of this Section. Rulemaking shall not delay the full implementation of this Section. (i) Beginning on June 29, 2018, provisional eligibility for medical assistance under Article V of this Code, in
the form of a recipient identification number and any other necessary credentials to permit an applicant to receive covered services under Article V, must be issued to any applicant who has not received a determination on his or her application for Medicaid and Medicaid long-term care services filed simultaneously or, if already Medicaid enrolled, application for Medicaid long-term care services under Article V of this Code within the federally prescribed timeliness requirements for determinations on such applications. The Department of Healthcare and Family Services must maintain the applicant's provisional eligibility status until a determination is made on the individual's application for long-term care services. The Department of Healthcare and Family Services or the managed care organization, if applicable, must reimburse providers for services rendered during an applicant's provisional eligibility period. (1) Claims for services rendered to an applicant with | ||
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(2) An applicant with provisional eligibility status | ||
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(3) The Department of Healthcare and Family Services, | ||
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(Source: P.A. 101-101, eff. 1-1-20; 101-209, eff. 8-5-19; 101-265, eff. 8-9-19; 101-559, eff. 8-23-19; 102-558, eff. 8-20-21.) |
(305 ILCS 5/11-5.5) Sec. 11-5.5. Streamlining enrollment into the Medicare Savings Program. (a) The Department shall investigate how to align the Medicare Part D Low-Income Subsidy and Medicare Savings Program eligibility criteria. (b) The Department shall issue a report making recommendations on how to streamline enrollment into Medicare Savings Program benefits by July 1, 2022. (c) Within 90 days after issuing its report, the Department shall seek public feedback on those recommendations and plans. (d) By July 1, 2023, the Department shall implement the necessary changes to streamline enrollment into the Medicare Savings Program. The Department may adopt any rules necessary to implement the provisions of this paragraph.
(Source: P.A. 102-1037, eff. 6-2-22.) |
(305 ILCS 5/11-6) (from Ch. 23, par. 11-6)
Sec. 11-6. Decisions on applications. Within 10 days after a decision is
reached on an application, the applicant
shall be notified in writing of the decision. If the applicant resides in a facility licensed under the Nursing Home Care Act or a supportive living facility authorized under Section 5-5.01a, the facility shall also receive written notice of the decision, provided that the notification is related to a Department payment for services received by the applicant in the facility. Only facilities enrolled in and subject to a provider agreement under the medical assistance program under Article V may receive such notices of decisions. The Department shall
consider eligibility for, and the notice shall contain a decision on, each
of the following assistance programs for which the client may be
eligible based on the information contained in the application: Temporary
Assistance for Needy Families, Medical Assistance, Aid to the Aged, Blind
and Disabled, General Assistance (in the City of Chicago), and food stamps. No
decision shall be required for any
assistance program for which the applicant has expressly declined in
writing to apply. If the applicant is determined to
be eligible, the notice shall include a statement of the
amount of financial aid to be provided and a statement of the reasons for
any partial grant amounts. If the applicant is determined
ineligible for any public assistance the notice shall include the reason
why the applicant is ineligible. If the application for any public
assistance is denied, the notice shall include a statement defining the
applicant's right to appeal the decision.
The Illinois Department, by rule, shall determine the date on which
assistance shall begin for applicants determined eligible. That date may be
no later than 30 days after the date of the application.
Under no circumstances may any application be denied solely to meet an
application-processing deadline. As used in this Section, "application" also refers to requests for admission approval to facilities licensed under the Nursing Home Care Act or to supportive living facilities authorized under Section 5-5.01a.
(Source: P.A. 100-665, eff. 8-2-18; 100-863, eff. 8-14-18.)
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(305 ILCS 5/11-6.1) (from Ch. 23, par. 11-6.1)
Sec. 11-6.1.
Report of loss.
(a) (Blank).
(b) (Blank).
(c) The payee of a grant under this Code shall immediately report to the
Illinois Department the theft or other loss of any instrument used in
making a grant payment.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-6.2)
Sec. 11-6.2.
Electronic fingerprinting.
(a) The Illinois Department may implement a program to
prevent multiple enrollments of aid
recipients through the use of an electronic automated 2-digit fingerprint
matching
identification system in local offices.
The Illinois Department shall apply for any federal waivers or approvals
necessary to conduct this program.
(b) The fingerprints or their electronic representations collected and
maintained through the use of an automated
fingerprint matching identification system as authorized by this Section may
not be used, disclosed, or redisclosed for any purpose other than the
prevention of multiple enrollments of aid recipients, may not be used or
admitted in any criminal or civil investigation, prosecution, or proceeding,
other than a proceeding pursuant to Article VIII-A, and may not be disclosed in
response to a subpoena or other compulsory legal process or warrant or upon the
request or order of any agency, authority, division, office, or other private
or public entity or person, except that nothing contained in this subsection
prohibits disclosure in response to a subpoena issued by or on behalf of the
applicant or recipient who is the subject of
the record maintained as a part of the system. A person who knowingly makes
or obtains any unauthorized disclosure of data collected and maintained under
this Section through the use of an automated fingerprint matching
identification system is guilty of a Class A misdemeanor.
Data collected and maintained on the automated fingerprint matching
identification system shall be subject to the provisions of this Code relating
to unauthorized disclosure of confidential client information.
(c)
The system shall include the use of a photographic identification for every aid
recipient. The Illinois Department shall
insure that adequate training for county department
staff involved with the program will be provided.
(d) The assistance programs affected by the electronic fingerprinting
program shall be determined by rule. By applying or
maintaining
eligibility for those assistance programs,
applicants
and recipients must submit
to the electronic collection of their fingerprints as an additional method of
establishing eligibility. Applicants for and recipients of aid who fail to
submit to electronic fingerprinting shall be declared ineligible for those
assistance programs.
(e) This Section does not authorize or permit the termination, suspension,
or
diminution of aid except as elsewhere specifically authorized in this Code. If a proposed sanction is based on the use of an automated fingerprint matching
identification
system authorized pursuant to this Section, the sanction may not be imposed
unless the Illinois Department has verified the multiple
enrollment through an independent investigation.
(f) The Illinois Department shall conduct periodic audits to monitor
compliance with all laws and regulations regarding the automated fingerprint
matching identification system to insure that: (i) any records maintained
as part of the system are accurate and complete; (ii) effective software and
hardware designs
have been instituted with security features to prevent unauthorized access to
records; (iii) access to record information system facilities, systems
operating
environments, and data file contents, whether while in use or when stored in
a media library, is restricted to authorized personnel; (iv) operational
programs are used that will prohibit inquiry, record updates, or destruction of
records from any terminal
other than automated fingerprint matching identification system terminals that
are so designated; (v) operational programs are used to detect and store for
the output of designated Illinois Department and county department employees
all
unauthorized attempts to penetrate any electronic automated fingerprint
matching
identification system, program, or file; and (vi) adequate and timely
procedures exist
to insure
the recipient's or applicant's right to access and review of records for the
purpose of accuracy and completeness, including procedures for review of
information maintained about those individuals and for administrative review
(including procedures for administrative appeal) and necessary correction of
any claim by the individual to whom the information relates that the
information is inaccurate or incomplete.
(Source: P.A. 90-17, eff. 6-19-97; 91-599, eff. 8-14-99.)
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(305 ILCS 5/11-7) (from Ch. 23, par. 11-7)
Sec. 11-7. Notice of decisions to terminate aid - determination and
notice of other medical assistance available - additional notice in cases
of blind persons.
Whenever decision is made to terminate aid, the recipient shall be
notified in writing within 10 days following the decision. The notice shall
set out the specific reasons for the termination. In the case of a blind
person, the notice and statement of reasons shall be sent whenever aid is
withdrawn, suspended, revoked, or in any way changed. In the case of a recipient who resides at a long-term care facility, the notice and statement of reasons shall be sent to the recipient and to the long-term care facility.
The notice shall include a statement defining the recipient's right to
appeal.
Before any notice to terminate medical assistance is issued, the
Illinois Department shall determine whether the recipient is newly eligible
for any other medical assistance offered by the Illinois Department. For
all recipients found eligible as a result of this determination for other
medical assistance offered by the Illinois Department, the Illinois
Department shall provide other medical assistance effective as of the date
of the termination of the prior medical assistance.
(Source: P.A. 101-100, eff. 1-1-20.)
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(305 ILCS 5/11-8) (from Ch. 23, par. 11-8)
Sec. 11-8. Appeals - to whom taken. Applicants or recipients of aid
may, at any time within 60 days after the decision of the County
Department or local governmental unit, as the case may be, appeal a
decision denying or terminating aid, or granting aid in an amount which
is deemed inadequate, or changing, cancelling, revoking or suspending
grants as provided in Section 11-16, or determining to make a protective
payment under the provisions of Sections 3-5a or 4-9, or a decision by an
administrative review board to impose administrative safeguards as provided
in Section 8A-8. An appeal shall also lie when an application is not acted
upon within the time period after filing of the application as provided by rule
of the Illinois Department.
If an appeal is not made, the action of the County Department or
local governmental unit shall be final.
Appeals by applicants or recipients under Articles III, IV, or V
shall be taken to the Illinois Department.
Appeals by applicants or recipients under Article VI shall be taken
as follows:
(1) In counties under township organization (except | ||
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(2) In counties in excess of 3,000,000 population and | ||
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(3) In counties described in paragraph (2) appeals of | ||
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(4) In counties not under township organization, | ||
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In counties designated in paragraph (1) the Chairman or President of
the County Board shall appoint, with the advice and consent of the
county board, one or more alternate members of the Public Aid Committee.
All regular and alternate members shall be Supervisors of General
Assistance. In any appeal involving a local governmental unit whose
Supervisor of General Assistance is a member of the Committee, he shall
be replaced for that appeal by an alternate member designated by the
Chairman or President of the County Board, with the advice and consent
of the county board. In these counties not more than 3 of the 5 regular
appointees shall be members of the same political party unless the
political composition of the Supervisors of the General Assistance
precludes such a limitation. In these counties at least one member of the
Public Aid Committee shall be a person knowledgeable in the area of general
assistance and the regulations of the Illinois Department pertaining
thereto. If no member of the Committee possesses such knowledge, the
Illinois Department shall designate an employee of the Illinois Department
having such knowledge to be present at the Committee hearings to advise
the Committee.
In every county the County Board shall provide facilities for the
conduct of hearings on appeals under Article VI. All expenses incident
to such hearings shall be borne by the county except that in counties
under township organization in which the governing authority is a Board
of Commissioners (1) the salary and other expenses of the Commissioner
of Appeals shall be paid from General Assistance funds available for
administrative purposes, and (2) all expenses incident to such hearings
shall be borne by the township and the per diem and traveling expenses
of the township supervisors serving on the Public Aid Committee shall be
fixed and paid by their respective townships. In all other counties the
members of the Public Aid Committee shall receive the compensation and
expenses provided by law for attendance at meetings of the County Board.
In appeals under Article VI involving a governmental unit receiving
State funds, the Public Aid Committee and the Commissioner of Appeals
shall be bound by the rules and regulations of the Illinois Department
which are relevant to the issues on appeal, and shall file such reports
concerning appeals as the Illinois Department requests.
The members of each Public Aid Committee and the members of the Cook
County Townships Public Aid Committee are immune from personal liability in connection with their service on the committee to the same extent as an elected or appointed judge in this State is immune from personal liability in connection with the performance of his or her duties as judge. This immunity applies only to causes of action accruing on or after the effective date of this amendatory Act of the 94th General Assembly.
An appeal shall be without cost to the appellant and shall be made, at
the option of the appellant, either upon forms provided and prescribed by
the Illinois Department or, for appeals to a Public Aid Committee, upon
forms prescribed by the County Board; or an appeal may be made by calling a
toll-free number provided for that purpose by the Illinois Department and
providing the necessary information. The Illinois Department may assist
County Boards or a Commissioner of Appeals in the preparation of appeal
forms, or upon request of a County Board or Commissioner of Appeals may
furnish such forms. County Departments and local governmental units shall
render all possible aid to persons desiring to make an appeal. The
provisions of Sections 11-8.1 to 11-8.7, inclusive, shall apply to all
such appeals.
(Source: P.A. 93-295, eff. 7-22-03; 94-524, eff. 8-10-05.)
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(305 ILCS 5/11-8.1) (from Ch. 23, par. 11-8.1)
Sec. 11-8.1.
Appellants' rights.
(a) Upon receipt of an appeal the Illinois Department, Public Aid
Committee, or Commissioner of Appeals, as the case may be, shall review the
case. The appellant shall be entitled to appear in person and to be
represented by counsel. He shall be afforded an opportunity to present all
relevant matter in support of his claim for aid, or his objection to (a)
termination of aid, or (b) the amount of aid, or (c) a determination to
make a protective payment.
(b) Whenever any applicant appeals the denial of any application for
assistance and the reason for denial is due to the failure of the
applicant to comply with procedural requirements, including but not limited
to, failure to keep an appointment, failure to produce acceptable proof of
eligibility, or failure to request more time or assistance in obtaining
acceptable proof of eligibility, the denial shall be rescinded if at any
time before the decision on the appeal is made, the appellant complies with the
procedural requirements that caused the denial and all other requirements
necessary to process the application. When the denial is rescinded under
this subsection, the Illinois Department shall grant or deny the application
based upon all relevant substantive eligibility factors and issue a new
decision. If the application is approved, cash assistance shall begin
effective 30 calendar days after the original application date and the
starting date of all other assistance shall begin based on the original
application date.
(Source: P.A. 87-630.)
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(305 ILCS 5/11-8.2) (from Ch. 23, par. 11-8.2)
Sec. 11-8.2.
Venue; depositions.
The appeal shall be heard in the county where the appellant resides.
However, if the appellant is outside the State, the Illinois Department,
Public Aid Committee, or Commissioner of Appeals, as the case may be, may
take depositions from him and his witnesses or permit the appellant to present
all relevant matter in support of his claim through witnesses acting in his
behalf, or both by deposition or by testimony of witnesses, depending upon
the circumstances in each case.
Hearings under this Section and Section 11-8.1 may be conducted with
some or all of the parties, including the hearing officer, at different
locations connected with each other by telephone.
(Source: P.A. 87-860.)
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(305 ILCS 5/11-8.3) (from Ch. 23, par. 11-8.3)
Sec. 11-8.3.
Hearing officers - Subpoenas.
Any qualified officer or employee
of the Illinois Department, a
County Board, or member of the staff of a Commissioner of Appeals, as
the case may be, designated in writing to so act by the Director of the
Department, Chairman or President of the County Board, or Commissioner
of Appeals, may conduct hearings on appeals and may compel, by subpoena,
the attendance and testimony of witnesses and the production of books
and papers, and administer oaths to witnesses. Wherever feasible, the
Public Aid Committee shall itself conduct hearings on appeals by
applicants for or recipients of aid under Article VI. No person
shall be compelled to attend a hearing at a place outside the county in
which he resides. Subpoenas may be served as provided for in civil
actions. The fees of witnesses for attendance and travel shall be the
same as the fees of witnesses before the circuit court and shall be paid
as an expense of administration of the County Department or the local
governmental unit, as the case may be.
If a witness refuses to attend or testify, or to produce books or
papers, concerning any matter upon which he might be lawfully examined,
the circuit court of the county wherein the hearing is held, upon
application of the Illinois Department, Public Aid Committee, or
Commissioner of Appeals, as the case may be, may compel obedience by
proceedings as for contempt as in case of a like refusal to obey a
similar order of the court.
(Source: P.A. 81-1085.)
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(305 ILCS 5/11-8.4) (from Ch. 23, par. 11-8.4)
Sec. 11-8.4.
Hearings not bound by technical rules of evidence or procedure.
The Illinois Department, Public Aid Committees and Commissioner of
Appeals shall not be bound by common law or statutory rules of evidence, or
by technical or formal rules of procedure, but shall conduct their hearings
in such manner as seems best calculated to conform to substantial justice
and the spirit of this Code. They may make such additional investigation as
they may deem necessary, and shall make such decision as to the granting of
aid and the amounts thereof as in their opinion is justified and in
conformity with this Code.
(Source: Laws 1967, p. 2302.)
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(305 ILCS 5/11-8.5) (from Ch. 23, par. 11-8.5)
Sec. 11-8.5.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-8.6) (from Ch. 23, par. 11-8.6)
Sec. 11-8.6.
Decision - time and effect.
A decision on appeal shall be
given to the interested parties within 90 days from the date of the filing of
the appeal, unless additional time is required for a proper disposition of the
appeal. All decisions on appeals shall be binding upon and complied with by
the County Departments and local governmental units.
(Source: P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/11-8.7) (from Ch. 23, par. 11-8.7)
Sec. 11-8.7.
Judicial review.
The provisions of the Administrative Review
Law, as amended, and the rules
adopted pursuant thereto, shall apply to
and govern all proceedings for the judicial review of final
administrative decisions of the Illinois Department on appeals by
applicants or recipients under Articles III, IV, or V. The term
"administrative decision" is defined as in Section 3-101 of the Code of Civil
Procedure.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-9) (from Ch. 23, par. 11-9)
Sec. 11-9. Protection of records; exceptions. For the protection of applicants and recipients, the Illinois Department,
the county departments and local governmental units and their respective
officers and employees are prohibited, except as hereinafter provided, from
disclosing the contents of any records, files, papers and communications,
except for purposes directly connected with the administration of public
aid under this Code.
In any judicial proceeding, except a proceeding directly concerned with
the administration of programs provided for in this Code, such records,
files, papers and communications, and their contents shall be deemed
privileged communications and shall be disclosed only upon the order of the
court, where the court finds such to be necessary in the interest of justice.
The Illinois Department shall establish and enforce reasonable rules and
regulations governing the custody, use and preservation of the records,
papers, files, and communications of the Illinois Department, the county
departments and local governmental units receiving State or Federal funds
or aid. The governing body of other local governmental units shall in like
manner establish and enforce rules and regulations governing the same matters.
The contents of case files pertaining to recipients under Articles IV, V,
and VI shall be made available without subpoena or formal notice to the
officers of any court, to all law enforcement agencies, and to such other persons
or
agencies as from time to time may be authorized by any court.
In particular, the contents of those case files shall be made available upon
request to a law enforcement agency for the purpose of determining the current
address of a recipient with respect to whom an arrest warrant is outstanding,
and
the current address of a recipient who was a victim of a felony or a
witness to a felony shall be made available upon
request to a State's Attorney of this State or a State's Attorney's
investigator. Information shall also be disclosed to
the Illinois State Scholarship
Commission pursuant to an investigation or audit by the Illinois State
Scholarship Commission of a delinquent student loan or monetary award.
This Section does not prevent the Illinois Department and local governmental
units from reporting to appropriate law enforcement officials the desertion
or abandonment by a parent of a child, as a result of which financial aid
has been necessitated under Articles IV, V, or VI, or reporting
to
appropriate law enforcement officials instances in which a mother under
age 18 has a child out of wedlock and is an applicant for or recipient of
aid under any Article of this Code. The Illinois Department may provide
by rule for the county departments and local governmental units to initiate
proceedings under the Juvenile Court Act of 1987 to have children declared
to be neglected when they deem
such action necessary to protect the children from immoral influences
present in their home or surroundings.
This Section does not preclude the full exercise of the powers of the Board
of Public Aid Commissioners to inspect records and documents, as provided
for all advisory boards pursuant to Section 5-505 of the
Departments of State Government Law (20 ILCS 5/5-505).
This Section does not preclude exchanges of information among the Department of Healthcare and Family Services (formerly Illinois
Department of Public Aid), the Department of Human Services (as successor to the
Department of Public Aid), and the Illinois Department of Revenue for the
purpose of verifying sources and amounts of income and for other purposes
directly connected with the administration of this Code and of the Illinois
Income Tax Act.
The provisions of this Section and of Section 11-11 as they apply to
applicants and recipients of public aid under Article V shall
be operative only to the extent that they do not conflict with any Federal
law or regulation governing Federal grants to this State for such programs.
The Department of Healthcare and Family Services and the Department of Human Services
(as successor to the Illinois Department of Public Aid) shall enter into an
inter-agency agreement with the
Department of Children and Family Services to establish a procedure by which
employees of the Department of Children and Family Services may have immediate
access to records,
files, papers, and communications (except medical, alcohol or drug assessment
or treatment, mental health, or any other medical records) of the Illinois
Department, county
departments, and local governmental units receiving State or federal funds or
aid, if the Department of Children and Family Services determines the
information is necessary to perform its duties under the Abused and Neglected
Child Reporting Act, the Child Care Act of 1969, and the Children and Family
Services Act.
(Source: P.A. 100-201, eff. 8-18-17.)
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(305 ILCS 5/11-10) (from Ch. 23, par. 11-10)
Sec. 11-10.
Names
furnished other agencies.
Whenever, under provisions of law, names and addresses of recipients of
public aid are furnished to or held by any other agency or department of
government, the agency or department of government shall adopt regulations
necessary to prevent the publication of lists thereof or their use for
purposes not directly connected with the administration of this Code, except
that lists of that information shall be made available upon request to a law
enforcement agency for the purpose of determining the current address of a
recipient with respect to whom an arrest warrant is outstanding as provided in
Section 11-9.
(Source: P.A. 89-583, eff. 1-1-97.)
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(305 ILCS 5/11-12) (from Ch. 23, par. 11-12)
Sec. 11-12.
Penalty for publication, use for political or commercial purposes.
It is unlawful to use or publish any names or list of names of
recipients secured from records maintained in the offices of the county
departments or local governmental units except in conformity with
regulations adopted by the Illinois Department.
It is unlawful, for commercial or political purposes of any nature, for
any person, body, association, firm, corporation, or other agency to
solicit, receive, make use of, or to authorize, knowingly permit,
participate in or acquiesce in the use of, any lists of names of, or any
information concerning, persons applying for or receiving public aid,
directly or indirectly derived from the records, papers, files, or
communications of the Illinois Department, the county departments, or local
governmental units, or acquired in the course of performance of official
duties. A violation of this Section shall constitute a Class B misdemeanor.
(Source: P.A. 77-2344.)
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(305 ILCS 5/11-13) (from Ch. 23, par. 11-13)
Sec. 11-13. Conditions For Receipt of Vendor Payments - Limitation Period
For Vendor Action - Penalty For Violation. A vendor payment, as defined in
Section 2-5 of Article II, shall constitute payment in full for the goods
or services covered thereby. Acceptance of the payment by or in behalf of
the vendor shall bar him from obtaining, or attempting to obtain,
additional payment therefor from the recipient or any other person. A
vendor payment shall not, however, bar recovery of the value of goods and
services the obligation for which, under the rules and regulations of the
Illinois Department, is to be met from the income and resources available
to the recipient, and in respect to which the vendor payment of the
Illinois Department or the local governmental unit represents
supplementation of such available income and resources.
Vendors seeking to enforce obligations of a governmental unit or the
Illinois Department for goods or services (1) furnished to or in behalf of
recipients and (2) subject to a vendor payment as defined in Section 2-5,
shall commence their actions in the appropriate Circuit Court or the Court
of Claims, as the case may require, within one year next after the cause of
action accrued.
A cause of action accrues within the meaning of this Section upon the following date:
(1) If the vendor can prove that he submitted a bill | ||
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(2) If the vendor cannot prove that he submitted a | ||
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In the case of long term care facilities, where the Illinois Department initiates the monthly billing process for the vendor, the cause of action shall accrue 12 months after the last day of the month the service was rendered. This paragraph governs only vendor payments as
defined in this Code and as limited by regulations of the Illinois
Department; it does not apply to goods or services purchased or contracted
for by a recipient under circumstances in which the payment is to be made
directly by the recipient.
Any vendor who accepts a vendor payment and who knowingly obtains or
attempts to obtain additional payment for the goods or services covered by
the vendor payment from the recipient or any other person shall be guilty
of a Class B misdemeanor.
(Source: P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/11-14) (from Ch. 23, par. 11-14)
Sec. 11-14.
Voluntary repayments.
A recipient or former recipient of financial aid under this Code, or a
responsible relative or other person in behalf of the recipient or former
recipient may voluntarily repay all or part of the financial aid rendered
to him and in respect to which repayment was not required by this Code or
other laws of this State.
Repayments may be made to the County Department or to the local
governmental unit which rendered the financial aid. If there is more than
one such local governmental unit, the repayment may be made to any one of
such governmental units and the local governmental unit to which the
repayment is made shall transmit to the other unit or units a proportionate
share of the repayment which shall be in the ratio of the assistance
rendered by each unit to the total assistance rendered by all units.
The fact of such voluntary repayment and the amount thereof shall be
duly entered on the public aid disbursement record, and in the case record
of the recipient if available, and designated in such manner as will
clearly distinguish such repayment as made voluntarily and without
compulsion.
Voluntary repayments to County Departments shall be paid into the
general fund in the State Treasury, or into such other fund as may be
established by law for such voluntary repayments. Repayments to local
governmental units shall be paid into the general assistance fund of the
governmental unit or other special fund into which general assistance
moneys of the local governmental unit are paid.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/11-14.5)
Sec. 11-14.5.
Overpayment; recovery.
If an applicant or recipient receives
any form of public aid from the Illinois Department or a local governmental
unit to which he or she is not
entitled, the Illinois Department or local governmental unit may determine
that the applicant or recipient
has received an overpayment of public aid. The Illinois Department may
determine that an overpayment has been received regardless of any determination
of the cause of the overpayment, including but not limited to a determination
that the overpayment was caused by an error of the Illinois Department or
local governmental unit. The
Illinois Department or local governmental unit may attempt to recover the
overpayment by recoupment from
future assistance payments or food stamps or any other legal means consistent
with State and federal law.
(Source: P.A. 89-673, eff. 8-14-96; 90-517, eff. 8-22-97.)
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(305 ILCS 5/11-15) (from Ch. 23, par. 11-15) Sec. 11-15. Application requirements. (1) An application for financial aid shall be filed in writing by the person requesting aid and, in the case of a request for family aid, by the head of that family, except as otherwise permitted in paragraph (2). Applications for aid under Articles III, IV, and V shall be filed in writing with any local office of the Department of Human Services in the manner prescribed by the Department. Applications for aid under Article VI shall be filed in writing with the local governmental unit upon forms approved by the Department. Each applicant shall provide information as to the amount of property, real and personal, owned by him or her within the period of time preceding the application as required under Sections 3-1.3, 4-1.11, and 5-2.1 of this Code. The applicant shall also furnish information concerning all income, money contributions, and other support from any source, and the beneficiary and the amount or cash surrender or loan value of all insurance policies held by himself or herself or any member of his family for whom aid is requested. (2) An application, in all instances to be in writing, may be filed in behalf of a person considered to be in need of financial aid under Articles III, IV, V, or VI only if the person (a) has been adjudged to be under legal disability; or (b) is unable because of minority or physical or | ||
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(c) in the case of need for funeral and burial, died | ||
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Applications in behalf of persons specified in (a) and (b) shall be filed by the applicant's legal guardian or, if a guardian has not been appointed or the applicant has no legal guardian or the guardian is not available, by a relative or other person, acceptable under the rules of the Illinois Department, who is able to furnish the required information. Applications in behalf of persons specified in (c) shall be filed by any next of kin of the deceased who is not under legal disability or, if there are no such next of kin or they are unknown or unavailable, by a person, acceptable under the rules of the Illinois Department, who is able to furnish the required information. Notwithstanding any other provision of this paragraph (2), a minor may sign and file an application on the minor's own behalf if the application is for the Article V family planning program established under Section 5-5 by Public Act 102-665. (3) The application shall contain a written declaration to be signed by the applicant, or in behalf of the applicant by a person qualified under paragraph (2), in substantially the following form, the parenthetical references being applicable to an application filed by a person in behalf of the applicant: "I declare under penalties of perjury that I have examined this form and all accompanying statements or documents pertaining to the income and resources of myself (the applicant) or any member of my family (the applicant's family) included in this application for aid, or pertaining to any other matter having bearing upon my (the applicant's) eligibility for aid, and to the best of my knowledge and belief the information supplied is true, correct, and complete". (4) If an application for financial aid is filed for a family, and any person in that family is under 18 years of age, the application shall be accompanied by the following for each such person under 18 years of age: (i) a copy of the person's birth certificate, or (ii) other reliable proof, as determined by the | ||
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The Illinois Department shall provide information to all families, orally by an intake worker and in writing when the application is filed, about the availability and location of immunization services. (5) Once an applicant is determined eligible for aid, he or she has the right to request to have the case transferred to another local office of the Department of Human Services for his or her convenience based on one of the following factors: the location of his or her employer; the location of his or her child care provider; access to reliable transportation; or the location of a social service provider that he or she sees on a regular basis. Within 5 business days after the request for transfer, the Department shall transfer the case, assign a caseworker, make appropriate entries in the computer system, and issue a written notice to the recipient that includes the name of and contact information for the caseworker. The location of the recipient's case may be reconsidered on the recipient's request or at the time of redetermination of eligibility. (Source: P.A. 103-786, eff. 8-7-24.) |
(305 ILCS 5/11-16) (from Ch. 23, par. 11-16)
Sec. 11-16. Changes in grants; cancellations, revocations, suspensions.
(a) All grants of financial aid under this Code shall be considered as
frequently as may be required by the rules of the Illinois Department.
The Department of Healthcare and Family Services shall consider grants of financial aid to
children who are eligible under Article V of this Code at least annually and
shall take into account those reports filed, or required to be filed, pursuant
to Sections 11-18 and 11-19.
After such investigation as may be necessary, the amount and manner of
giving aid may be changed or the aid may be entirely withdrawn if the
County Department, local governmental unit, or Illinois Department finds
that the recipient's circumstances have altered sufficiently to warrant
such action. Financial aid may at any time be canceled or revoked for cause
or suspended for such period as may be proper.
(b) Whenever any such grant of financial aid is cancelled, revoked,
reduced, or terminated because of the failure of the recipient to cooperate
with the Department, including but not limited to the failure to keep an
appointment, attend a meeting, or produce proof or verification of
eligibility or need, the grant shall be reinstated in full, retroactive to
the date of the change in or termination of the grant, provided that within
10 working days after the first day the financial aid would have been
available, the recipient cooperates with the Department and is not
otherwise ineligible for benefits for the period in question. This
subsection (b) does not apply to sanctions imposed for the failure of any
recipient to participate as required in the child support enforcement
program or in any educational, training, or employment program under this
Code or any other sanction under Section 4-21, nor does this subsection (b)
apply to any cancellation, revocation,
reduction, termination, or sanction imposed for the failure of any recipient to
cooperate in the monthly reporting process or the quarterly reporting
process.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/11-17) (from Ch. 23, par. 11-17)
Sec. 11-17.
Duplication or supplementation of aid prohibited-Exceptions.
Except (1) for Medical Assistance provided under Article V, or (2)
when necessary to accomplish the purposes of this Code, where not
inconsistent therewith, and subject to the rules of the Illinois
Department, a person receiving aid under any one of Articles III, IV, or VI of
this Code shall not at the same time receive aid under any other
of such Articles or any other financial aid from the State, any political
subdivision thereof, or any municipal corporation therein.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-18) (from Ch. 23, par. 11-18)
Sec. 11-18.
Duty
to report changes in circumstances.
It is the duty of every applicant and recipient to notify promptly the
county department or the supervisor of general assistance, as the case may
be, of any change of status with respect to his property, or need, or
family composition, amount of income, money contributions and other
support, from whatever source, occurring, in the case of an applicant,
between the time of his filing an application for financial aid and the
issuance of the grant, and, in the case of a recipient, occurring at any
time during the period that he receives financial aid.
If an applicant or recipient fails to give prompt notice of changes in
his circumstances, and as a result financial aid is given to which he is
not entitled, he shall be liable to the county department or to the local
governmental unit, as the case may be, for refunding a sum of money up to
but not in excess of the entire amount of financial aid provided. Unless
the refund is made the amount may be recovered in a civil action.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/11-19) (from Ch. 23, par. 11-19)
Sec. 11-19.
Reports by recipients.
Every recipient who is of legal age, and every grantee of record of aid
provided for a minor recipient, shall file
with the county department or the local governmental unit, as the case may
be, a statement in respect to any change occurring in his status since his
application was made or the filing of his last such report, whichever is
applicable. The report shall set out any changes occurring in respect to
his property or need, family composition, amount of income, money
contributions or other support, from whatever source.
Such reports shall be required to be filed as often as may be specified
by rule, and the required frequency of such reports may vary by program,
geographic area, condition of employment, or such other differentiation as
may be specified by rule.
The Illinois Department may require that information in the reports filed
under this Section include a child immunization history for recipients age 6
and under not attending school. For recipients who report that they have not
obtained the immunizations in accordance with recommended schedules, the
Illinois Department shall respond by providing information about the
availability and location of immunization services and shall transmit the
immunization history information to the Healthy Kids Program administered under
Section 5-19 of this Code.
(Source: P.A. 88-342.)
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(305 ILCS 5/11-20) (from Ch. 23, par. 11-20)
Sec. 11-20. Employment registration; duty to accept employment. This
Section applies to employment and training
programs other than those for recipients of assistance under Article IV.
(1) Each applicant or recipient and dependent member of
the family age 16 or over who is able to engage in employment and who is
unemployed, or employed for less than the full working time for the occupation
in which he or she is engaged, shall maintain a current registration for
employment or additional employment with the system of free public employment
offices maintained in this State by the State Department of Employment
Security under the Public Employment Office Act and shall utilize the job
placement
services and other facilities of such offices unless the Illinois
Department otherwise provides by rule for programs administered by the
Illinois Department.
(2) Every person age 16 or over shall be deemed "able to engage in
employment", as that term is used herein, unless (a) the person has an
illness certified by the attending practitioner as precluding his or her
engagement in employment of any type for a time period stated in the
practitioner's certification; or (b) the person has a medically determinable
physical or mental impairment, disease or loss of indefinite duration and
of such severity that he or she cannot perform labor or services in any
type of gainful work which exists in the national economy, including work
adjusted for persons with physical or mental disabilities; or (c) the person
is among the classes of persons exempted by paragraph 5 of this Section.
A person described in clauses (a), (b) or (c) of the preceding sentence
shall be classified as "temporarily unemployable". The Illinois Department
shall provide by rule for periodic review of the circumstances of persons
classified as "temporarily unemployable".
(3) The Illinois Department shall provide through rules and regulations
for sanctions against applicants and recipients of aid under this Code
who fail or refuse to cooperate, without good cause, as defined by rule of
the Illinois Department, to accept a bona fide offer of employment in which
he or she is able to engage either in the community of the person's
residence or within reasonable commuting distance therefrom.
The Illinois Department may provide by rule for the grant or continuation
of aid for a temporary period, if federal law or regulation so permits or
requires, to a person who refuses employment without good cause if he or
she accepts counseling or other services designed to increase motivation
and incentives for accepting employment.
(4) Without limiting other criteria which the Illinois Department may
establish, it shall be good cause of refusal if
(a) the wage does not meet applicable minimum wage | ||
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(b) there being no applicable minimum wage as | ||
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(c) acceptance of the offer involves a substantial | ||
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(5) The requirements of registration and acceptance of employment shall
not apply (a) to a parent or other person needed at home
to provide personal care and supervision to a child or children unless,
in accordance with the rules and regulations of the Illinois Department,
suitable arrangements have been or can be made for such care and
supervision
during the hours of the day the parent or other person is out of the home
because of employment; (b) to a person age 16 or over in regular attendance
in school, as defined in Section 4-1.1; or (c) to a person whose presence
in the home on a substantially continuous basis is required because of the
illness or incapacity of another member of the household.
(Source: P.A. 99-143, eff. 7-27-15.)
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(305 ILCS 5/11-20.1) (from Ch. 23, par. 11-20.1)
Sec. 11-20.1. Employment; Rights of recipient and obligations of
Illinois Department when recipients become employed; Assistance when
a recipient has employment or earned income or both. (a) When a recipient reports employment or earned income, or both, or
the Illinois Department otherwise learns of a recipient's employment or
earned income, or both, the Illinois Department shall provide the recipient
with:
(1) An explanation of how the earned income will | ||
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(2) An explanation of the Work Pays budgeting | ||
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(3) An explanation of how the earned income will | ||
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(4) The names and telephone numbers of all | ||
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(5) An explanation of the recipient's | ||
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(6) If the recipient will continue to receive a | ||
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(7) An explanation of Kidcare, Family Assist, Family | ||
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(8) An explanation of the medical assistance the | ||
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(9) An explanation of the availability of a child | ||
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(10) (Blank).
(11) (Blank).
(11a) (Blank).
(12) (Blank).
(13) An explanation of the availability of payment | ||
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(14) An explanation of the job retention component | ||
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(15) A statement of the types of assistance that will | ||
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(16) If the recipient will not continue to receive a | ||
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(17) An explanation of the availability of payments | ||
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(18) If the recipient will not continue to receive a | ||
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(19) An explanation of the earned income tax credit | ||
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(20) An explanation of the education and training | ||
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(b) The information listed in subsection (a) shall be provided to the
recipient on an individual basis during an in-person meeting with a
representative of the Illinois Department. The individual in-person
meeting shall be held at a time which does not conflict with the
recipient's work schedule within 30 days of the date the recipient begins
working. If the recipient informs the Illinois Department that an
in-person meeting would be inconvenient, the Illinois Department may
provide the information during a home visit, by telephone, or by mail
within 30 days of the date the recipient begins working, whichever the
client prefers.
(c) At the conclusion of the meeting described in subsection (b), the
Illinois Department shall ensure that all case transfers and calculations
of benefits necessitated by the recipient's employment or receipt of earned
income have been performed, that applications have been made or provided
for all benefits for which the person must apply or reapply, and that the
person has received payment for initial expenses of employment.
(d) In food stamp cases in which an applicant or recipient reports earned income, the applicant's or recipient's employment shall be presumed to be a hardship for purposes of scheduling an in-person meeting with a
representative of the Illinois Department and an in-person meeting shall be waived. (Source: P.A. 96-867, eff. 1-1-11.)
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(305 ILCS 5/11-22) (from Ch. 23, par. 11-22)
Sec. 11-22. Charge upon claims and causes of action for injuries. The Illinois Department shall have a charge upon all claims, demands and
causes of action for injuries to an applicant for or recipient of (i)
financial aid under Articles III, IV, and V, (ii) health care benefits provided under the Covering ALL KIDS Health Insurance Act, or (iii) health care benefits provided under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008 for the total
amount of
medical assistance provided the recipient from the time of injury to the
date of recovery upon such claim, demand or cause of action. In addition, if
the applicant or recipient was employable, as defined by the Department, at
the time of the injury, the Department shall also have a charge upon any
such claims, demands and causes of action for the total amount of aid
provided to the recipient and his
dependents, including all cash assistance and medical assistance
only to the extent includable in the claimant's action, from the
time of injury to the date of recovery upon such
claim, demand or cause of action. Any definition of "employable"
adopted by the Department shall apply only to persons above the age of
compulsory school attendance.
If the injured person was employable at the time of the injury and is
provided aid under Articles III, IV, or V and any dependent or
member of his family is provided aid under Article VI, or vice versa,
both the Illinois Department and the local governmental unit shall have
a charge upon such claims, demands and causes of action for the aid
provided to the injured person and any
dependent member of his family, including all cash assistance, medical
assistance and food stamps, from the time of the injury to the date
of recovery.
"Recipient", as used herein, means (i) in the case of financial aid provided under this Code, the grantee of record and any
persons whose needs are included in the financial aid provided to the
grantee of record or otherwise met by grants under the appropriate
Article of this Code for which such person is eligible, (ii) in the case of health care benefits provided under the Covering ALL KIDS Health Insurance Act, the child to whom those benefits are provided, and (iii) in the case of health care benefits provided under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, the veteran to whom benefits are provided.
In each case, the notice shall be served by certified mail or
registered mail, or by facsimile or electronic messaging when requested by the party or parties against whom the applicant or recipient has a claim, demand, or cause of action, upon the party or parties against whom the applicant or
recipient has a claim, demand or cause of action. The notice shall
claim the charge and describe the interest the Illinois Department, the
local governmental unit, or the county, has in the claim, demand, or
cause of action. The charge shall attach to any verdict or judgment
entered and to any money or property which may be recovered on account
of such claim, demand, cause of action or suit from and after the time
of the service of the notice.
On petition filed by the Illinois Department, or by the local
governmental unit or county if either is claiming a charge, or by the
recipient, or by the defendant, the court, on written notice to all
interested parties, may adjudicate the rights of the parties and enforce
the charge. The court may approve the settlement of any claim, demand
or cause of action either before or after a verdict, and nothing in this
Section shall be construed as requiring the actual trial or final
adjudication of any claim, demand or cause of action upon which the
Illinois Department, the local governmental unit or county has charge.
The court may determine what portion of the recovery shall be paid to
the injured person and what portion shall be paid to the Illinois
Department, the local governmental unit or county having a charge
against the recovery.
In making this determination, the court shall conduct an evidentiary hearing
and shall consider competent evidence pertaining
to the following matters:
(1) the amount of the charge sought to be enforced | ||
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(2) the amount, if any, of the attorney's fees and | ||
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(3) the total hospital, doctor and other medical | ||
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(4) whether the recovery represents less than | ||
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(5) the age of the recipient and of persons dependent | ||
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(6) the realistic ability of the recipient to repay | ||
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The burden of producing evidence sufficient to support the exercise by
the court of its discretion to reduce the amount of a proven charge sought
to be enforced against the recovery shall rest with the party seeking such reduction.
The court may reduce and apportion the Illinois
Department's lien proportionate to the recovery of the claimant. The court may
consider the nature and extent of the injury, economic and noneconomic
loss, settlement offers, comparative negligence as it applies to the case
at hand, hospital costs, physician costs, and all other appropriate costs.
The Illinois Department shall pay its pro rata share of the attorney fees
based on the Illinois Department's lien as it compares to the total
settlement agreed upon. This Section shall not affect the priority of an
attorney's lien under the Attorneys Lien Act. The charges of
the Illinois Department described in this Section, however, shall take
priority over all other liens and charges existing under the laws of the
State of Illinois with the exception of the attorney's lien under said statute.
Whenever the Department or any unit of local government
has a statutory charge under this Section against a recovery for damages
incurred by a recipient because of its advancement of any assistance, such
charge shall not be satisfied out of any recovery until the attorney's claim
for fees is satisfied, irrespective of whether or not an action based on
recipient's claim has been filed in court.
This Section shall be inapplicable to any claim, demand or cause of
action arising under (a) the Workers' Compensation Act or the predecessor
Workers' Compensation Act
of
June 28, 1913, (b) the Workers' Occupational Diseases Act or the predecessor
Workers' Occupational
Diseases Act of March 16, 1936; and (c) the Wrongful Death Act.
(Source: P.A. 98-73, eff. 7-15-13.)
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(305 ILCS 5/11-22a) (from Ch. 23, par. 11-22a)
Sec. 11-22a. Right of Subrogation. To the extent of the amount of (i) medical
assistance provided by the Department to or on behalf of a recipient under
Article V or VI, (ii) health care benefits provided for a child under the Covering ALL KIDS Health Insurance Act, or (iii) health care benefits provided to a veteran under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, the Department shall be
subrogated
to any right of
recovery such recipient may have under the terms of any private or public
health care coverage or casualty coverage, including coverage under the
"Workers' Compensation Act", approved July 9, 1951, as amended, or the
"Workers' Occupational Diseases Act", approved July 9, 1951, as amended,
without the necessity of assignment of claim or other authorization to secure
the right of recovery to the Department. To enforce its subrogation right, the
Department may (i) intervene or join in an action or proceeding brought by the
recipient, his or her guardian, personal representative, estate, dependents, or
survivors against any person or public or private entity that may be liable;
(ii) institute and prosecute legal proceedings against any person or public or
private entity that may be liable for the cost of such services; or (iii)
institute and prosecute legal proceedings, to the extent necessary to reimburse
the Illinois Department for its costs, against any noncustodial parent who (A)
is required by court or administrative order to provide insurance or other
coverage of the cost of health care services for a child eligible for medical
assistance under this Code and (B) has received payment from a third party for
the costs of those services but has not used the payments to reimburse either
the other parent or the guardian of the child or the provider of the services.
(Source: P.A. 94-693, eff. 7-1-06; 94-816, eff. 5-30-06; 95-755, eff. 7-25-08.)
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(305 ILCS 5/11-22b) (from Ch. 23, par. 11-22b)
Sec. 11-22b. Recoveries.
(a) As used in this Section:
(1) "Carrier" means any insurer, including any | ||
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(2) "Beneficiary" means any person or their | ||
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(b)(1) When benefits are provided or will be provided to a beneficiary
under this Code, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008 because of an injury for which another person is liable, or
for which a carrier is liable in accordance with the provisions of any
policy of insurance issued pursuant to the Illinois Insurance Code, the
Illinois Department shall have a right to recover from such person or carrier
the reasonable value of benefits so provided. The Attorney General may, to
enforce such right, institute and prosecute legal proceedings against the
third person or carrier who may be liable for the injury in an appropriate
court, either in the name of the Illinois Department or in the name of the
injured person, his guardian, personal representative, estate, or survivors.
(2) The Department may:
(A) compromise or settle and release any such claim | ||
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(B) waive any such claims for benefits provided under | ||
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(3) No action taken on behalf of the Department pursuant to this Section
or any judgment rendered in such action shall be a bar to any action upon
the claim or cause of action of the beneficiary, his guardian, conservator,
personal representative, estate, dependents or survivors against the third
person who may be liable for the injury, or shall operate to deny to the
beneficiary the recovery for that portion of any damages not covered hereunder.
(c)(1) When an action is brought by the Department pursuant to
subsection (b), it shall be commenced within the period prescribed by
Article XIII of the Code of Civil Procedure.
However, the Department may not commence the action prior to 5 months
before the end of the applicable period prescribed by Article XIII of the
Code of Civil Procedure. Thirty days prior to commencing an action, the
Department shall notify the beneficiary of the Department's intent to
commence such an action.
(2) The death of the beneficiary does not abate any right of action
established by subsection (b).
(3) When an action or claim is brought by persons entitled to bring such
actions or assert such claims against a third person who may be liable for
causing the death of a beneficiary, any settlement, judgment or award
obtained is subject to the Department's claim for reimbursement of the
benefits provided to the beneficiary under this Code, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008.
(4) When the action or claim is brought by the beneficiary alone and
the beneficiary incurs a personal liability to pay attorney's fees and
costs of litigation, the Department's claim for reimbursement of the
benefits provided to the beneficiary shall be the full amount of benefits
paid on behalf of the beneficiary under this Code, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008 less a pro rata
share which represents the Department's reasonable share of attorney's fees
paid by the beneficiary and that portion of the cost of litigation expenses
determined by multiplying by the ratio of the full amount of the
expenditures of the full amount of the judgment, award or settlement.
(d)(1) If either the beneficiary or the Department brings an action or
claim against such third party or carrier, the beneficiary or the
Department shall within 30 days of filing the action give to the other
written notice by personal service or registered mail of the action or
claim and of the name of the court in which the
action or claim is brought. Proof of such notice shall be filed in such
action or claim. If an action or claim is brought by either the Department
or the beneficiary, the other may, at any time before trial on the facts,
become a party to such action or claim or shall consolidate his action or
claim with the other if brought independently.
(2) If an action or claim is brought by the Department pursuant to
subsection (b)(1), written notice to the beneficiary, guardian, personal
representative, estate or survivor given pursuant to this Section shall
advise him of his right to intervene in the proceeding, his right to obtain
a private attorney of his choice and the Department's right to recover the
reasonable value of the benefits provided.
(e) In the event of judgment or award in a suit or claim against such
third person or carrier:
(1) If the action or claim is prosecuted by the | ||
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(2) If the action or claim is prosecuted both by the | ||
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(f) The court shall, upon further application at any time
before the judgment or award is satisfied, allow as a further lien the
amount of any expenditures of the Department in payment of additional
benefits arising out of the same cause of action or claim provided on
behalf of the beneficiary under this Code, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, when such benefits were
provided or became payable subsequent to the original order.
(g) No judgment, award, or settlement in any action or claim by a
beneficiary to recover damages for injuries, when the Department has an
interest, shall be satisfied without first giving the Department notice and
a reasonable opportunity to perfect and satisfy its lien.
(h) When the Department has perfected a lien upon a judgment or award in
favor of a beneficiary against any third party for an injury for which the
beneficiary has received benefits under this Code, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, the Department shall be
entitled to a writ of execution as lien claimant to enforce payment of said
lien against such third party with interest and other accruing costs as in
the case of other executions. In the event the amount of such judgment or
award so recovered has been paid to the beneficiary, the Department shall
be entitled to a writ of execution against such beneficiary to the extent of
the Department's lien, with interest and other accruing costs as in the case
of other executions.
(i) Except as otherwise provided in this Section, notwithstanding any
other provision of law, the entire amount of any settlement of the injured
beneficiary's action or claim, with or without suit, is subject to the
Department's claim for reimbursement of the benefits provided and any lien
filed pursuant thereto to the same extent and subject to the same
limitations as in Section 11-22 of this Code.
(Source: P.A. 94-693, eff. 7-1-06; 94-816, eff. 5-30-06; 95-755, eff. 7-25-08.)
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(305 ILCS 5/11-22c) (from Ch. 23, par. 11-22c)
Sec. 11-22c. Recovery of back wages. (a) As used in this Section, "recipient" means any person
receiving financial assistance under Article IV or Article VI of this Code, receiving health care benefits under the Covering ALL KIDS Health Insurance Act, or receiving health care benefits under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008.
(b) If a recipient maintains any suit, charge or other court or
administrative action against an employer seeking back pay for a period
during which the recipient received financial assistance under Article IV
or Article VI of this Code, health care benefits under the Covering ALL KIDS Health Insurance Act, or health care benefits under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, the recipient shall report such fact to the
Department. To the extent of the amount of assistance provided to or on
behalf of the recipient under Article IV or Article VI, health care benefits provided under the Covering ALL KIDS Health Insurance Act, or health care benefits provided under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008, the Department may
by intervention or otherwise without the necessity of assignment of claim,
attach a lien on the recovery of back wages equal to the amount of
assistance provided by the Department to the recipient under Article IV or
Article VI, under the Covering ALL KIDS Health Insurance Act, or under the Veterans' Health Insurance Program Act or the Veterans' Health Insurance Program Act of 2008.
(Source: P.A. 94-693, eff. 7-1-06; 94-816, eff. 5-30-06; 95-755, eff. 7-25-08.)
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(305 ILCS 5/11-22d) Sec. 11-22d. Savings provisions. (a) Notwithstanding any amendments or provisions in this amendatory Act of the 102nd General Assembly which would make the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act inoperative, Sections 11-22a, 11-22b, and 11-22c of this Code shall remain in force for the commencement or continuation of any cause of action that (i) accrued prior to the effective date of this amendatory Act of the 102nd General Assembly or the date upon which the Department receives federal approval of the changes made to paragraph (6) of Section 5-2 by this amendatory Act of the 102nd General Assembly, whichever is later, and (ii) concerns the recovery of any amount expended by the State for health care benefits provided under the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act prior to those Acts becoming inoperative. Any timely action brought under Sections 11-22a, 11-22b, and 11-22c shall be decided in accordance with those Sections as they existed when the cause of action accrued. (b) Notwithstanding any amendments or provisions in this amendatory Act of the 102nd General Assembly which would make the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act inoperative, paragraph (2) of Section 12-9 of this Code shall remain in force as to recoveries made by the Department of Healthcare and Family Services from any cause of action commenced or continued in accordance with subsection (a).
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/11-23) (from Ch. 23, par. 11-23)
Sec. 11-23.
(Repealed).
(Source: P.A. 76-523. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-23.1) (from Ch. 23, par. 11-23.1)
Sec. 11-23.1.
(Repealed).
(Source: P.A. 89-507, eff. 7-1-97. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-25) (from Ch. 23, par. 11-25)
Sec. 11-25.
(Repealed).
(Source: P.A. 84-855. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-26) (from Ch. 23, par. 11-26)
Sec. 11-26. Recipient's abuse of medical care; restrictions on access to
medical care. (a) When the Department determines, on the basis of statistical norms and
medical judgment, that a medical care recipient has received medical services
in excess of need and with such frequency or in such a manner as to constitute
an abuse of the recipient's medical care privileges, the recipient's access to
medical care may be restricted.
(b) When the Department has determined that a recipient is abusing his or
her medical care privileges as described in this Section, it may require that
the recipient designate a primary provider type of the recipient's own choosing to assume
responsibility for the recipient's care. For the purposes of this subsection, "primary provider type" means a provider type
as determined by the Department. Instead of requiring a recipient to
make a designation as provided in this subsection, the Department, pursuant to
rules adopted by the Department and without regard to any choice of an entity
that the recipient might otherwise make, may initially designate a primary provider type provided that the primary provider type is willing to provide that care.
(c) When the Department has requested that a recipient designate a
primary provider type and the recipient fails or refuses to do so, the Department
may, after a reasonable period of time, assign the recipient to a primary provider type of its own choice and determination, provided such primary provider type is willing to provide such care.
(d) When a recipient has been restricted to a designated primary provider type, the
recipient may change the primary provider type:
(1) when the designated source becomes unavailable, | ||
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(2) when the designated primary provider type | ||
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(3) in other situations, as the Department shall | ||
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The Department shall, by rule, establish procedures for providing medical or
pharmaceutical services when the designated source becomes unavailable or
wishes to withdraw from any obligation as primary provider type, shall, by rule, take into
consideration the need for emergency or temporary medical assistance and shall
ensure that the recipient has continuous and unrestricted access to medical
care from the date on which such unavailability or withdrawal becomes effective
until such time as the recipient designates a primary provider type or a primary provider type willing to provide such care is designated by the Department
consistent with subsections (b) and (c) and such restriction becomes effective.
(e) Prior to initiating any action to restrict a recipient's access to
medical or pharmaceutical care, the Department shall notify the recipient
of its intended action. Such notification shall be in writing and shall set
forth the reasons for and nature of the proposed action. In addition, the
notification shall:
(1) inform the recipient that (i) the recipient has a | ||
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(2) inform the recipient that the recipient has a | ||
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(f) The Department shall, by rule or regulation, establish procedures for
appealing a determination to restrict a recipient's access to medical care,
which procedures shall, at a minimum, provide for a reasonable opportunity
to be heard and, where the appeal is denied, for a written statement
of the reason or reasons for such denial.
(g) Except as otherwise provided in this subsection, when a recipient
has had his or her medical card restricted for 4 full quarters (without regard
to any period of ineligibility for medical assistance under this Code, or any
period for which the recipient voluntarily terminates his or her receipt of
medical assistance, that may occur before the expiration of those 4 full
quarters), the Department shall reevaluate the recipient's medical usage to
determine whether it is still in excess of need and with such frequency or in
such a manner as to constitute an abuse of the receipt of medical assistance.
If it is still in excess of need, the restriction shall be continued for
another 4 full quarters. If it is no longer in excess of need, the restriction
shall be discontinued. If a recipient's access to medical care has been
restricted under this Section and the Department then determines, either at
reevaluation or after the restriction has been discontinued, to restrict the
recipient's access to medical care a second or subsequent time, the second or
subsequent restriction may be imposed for a period of more than 4 full
quarters. If the Department restricts a recipient's access to medical care for
a period of more than 4 full quarters, as determined by rule, the Department
shall reevaluate the recipient's medical usage after the end of the restriction
period rather than after the end of 4 full quarters. The Department shall
notify the recipient, in writing, of any decision to continue the restriction
and the reason or reasons therefor. A "quarter", for purposes of this Section,
shall be defined as one of the following 3-month periods of time:
January-March, April-June, July-September or October-December.
(h) In addition to any other recipient whose acquisition of medical care
is determined to be in excess of need, the Department may restrict the medical
care privileges of the following persons:
(1) recipients found to have loaned or altered their | ||
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(2) recipients found in possession of blank or forged | ||
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(3) recipients who knowingly assist providers in | ||
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The procedural safeguards in this Section shall apply to the above
individuals.
(i) Restrictions under this Section shall be in addition to and shall
not in any way be limited by or limit any actions taken under Article VIIIA
of this Code.
(Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)
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(305 ILCS 5/11-26.1) (from Ch. 23, par. 11-26.1)
Sec. 11-26.1.
Drug Utilization Review.
(a) The Illinois Department shall, within the time frames mandated by
federal law, implement a Drug Utilization Review Program (DUR), designed to
decrease overutilization of drugs through both prospective and
retrospective utilization review. The Illinois Department shall determine
the content of the DUR by rule.
(b) The Illinois Department may implement this Section as added by this
amendatory Act of 1991 through the use of emergency rules in accordance
with the provisions of Section 5.02 of the Illinois Administrative
Procedure Act. For purposes of the Illinois Administrative Procedure Act,
the adoption of rules to implement this Section as added by this amendatory
Act of 1991 shall be deemed an emergency and necessary for the public
interest, safety and welfare.
(Source: P.A. 87-14.)
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(305 ILCS 5/11-27) (from Ch. 23, par. 11-27)
Sec. 11-27.
Obtaining benefits after termination.
(a)
For the purpose of this Section, the term "entity" includes persons,
firms, corporations, associations and agencies.
(b) Subject to the provisions of Sections 8A-7, 8A-8 and 12-4.25, no
entity which has had its receipt of benefits or payments under this Code
terminated or suspended or its future receipt
barred by the Department shall,
while such disability
remains in effect, directly or indirectly:
(1) serve as a technical or other advisor to any entity which obtains,
attempts to obtain or seeks to obtain benefits or payments under this Code; or
(2) be an incorporator or member of the board of directors of any entity
which obtains, attempts to
obtain or seeks to obtain benefits or payments under this Code; or
(3) be an investor with or in any entity which obtains, attempts
to obtain or seeks to obtain benefits or payments under this Code.
(c) The Director may, by rule, establish procedures for any entity
aggrieved by the application of this Section to seek special permission to
continue receiving benefits or
payments under this Code or to seek reinstatement of benefits or
payments under this Code. Such entity must be otherwise eligible to
receive benefits or payments under this Code and in compliance with any
applicable requirement of this Code for reinstatement. If the Director
determines that the entity seeking such permission or reinstatement had no
part in the actions or conduct upon which the decision to suspend,
terminate or bar benefits was based, he may authorize the continued
participation by or reinstatement of the entity in such program or programs
as he may deem appropriate under all the circumstances and upon such terms
and conditions and under such probationary or other restrictions as he or
other provisions of this Code may require.
(d) Any entity which knowingly violates the provisions of this Section
or knowingly attempts or
conspires to violate the provisions of this Section shall be civilly liable
in a court of law for damages in an amount 3 times the value of all benefits or payments
obtained by such entity or $10,000, whichever sum is greater.
(e) The civil liability imposed under this Section shall be joint and
several and shall extend to any entity knowingly
seeking or attempting to obtain benefits under this
Code which, having the authority to refuse, knowingly associates with or
permits the association of a suspended, terminated or barred
entity as prohibited herein. Such liability
shall also extend to any
entity found guilty in a court of law of such unlawful association,
including the suspended, terminated or
barred entity. Liability shall arise when any such
entity knew, or under all of the circumstances reasonably should
have known, that it was engaging in or authorizing any activity prohibited herein.
(f) The Attorney General, or the State's Attorney in actions involving a
local governmental unit, may initiate court proceedings to recover benefits
or payments obtained in violation of this Section and shall, in addition to
any judgment obtained, be entitled to recover all court costs.
(g) Notwithstanding any provision of The Freedom of Information Act
or other State law, the Department shall make public the identity and
business address of every entity which has had its receipt of benefits or
payments under this Code suspended or terminated or its future receipt barred by the
Department. Each month, the Department shall publish a list of such
identities and addresses, which shall be mailed by the Department without
charge to associations and societies, including their affiliates and
components, of vendors providing goods, services or both to recipients of
medical assistance under this Code. The Department shall also mail such
list without charge to any other person or organization upon request.
(h) Nothing in this Section shall prohibit the Department from
pursuing and implementing any other remedy provided by this Code in
connection with the suspension, termination or reinstatement of receipt of
benefits or payments under this Code or the barring of receipt of future
benefits or payments under this Code.
(Source: P.A. 84-1254; 84-1438.)
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(305 ILCS 5/11-28) (from Ch. 23, par. 11-28)
Sec. 11-28.
Recipient Bill of Rights.
The Illinois Department shall
promulgate a Bill of Rights for Public Aid recipients which provides basic
information about financial and medical assistance and other social
services which are available through the Illinois Department and the rights
of recipients of and applicants for assistance or social services to due
process in reviewing and contesting decisions or actions of the Illinois
Department or a County Department. The Bill of Rights also shall contain
provisions to insure that all recipients and applicants are treated with
dignity and fairness. Copies of the Bill of Rights shall be prominently
posted in each County Department and other local service office maintained
by the Illinois Department or a County Department so that it will be
legible to recipients and applicants.
(Source: P.A. 87-528.)
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(305 ILCS 5/11-29) (from Ch. 23, par. 11-29)
Sec. 11-29.
Notification of Eligibility for Earned Income Tax Credit.
(a) The Illinois Department shall include the notice
regarding the availability of the federal earned income tax credit, in the
language provided under Section 20 of the Earned Income Tax Credit
Information Act, in any one scheduled mailing disbursed during the month of
January to: (1) any person receiving cash assistance under Article IV of
this Code; (2) any person receiving benefits under Article V of this Code who
does not also receive cash assistance; (3) any person receiving benefits
under Article VI of this Code who resides in the city of Chicago; and (4)
any person receiving benefits under the federal food stamp program who does
not also receive cash assistance under any Article of this Code.
(b) Before the annual mailing of the notice under subsection (a) of this
Section the Illinois Department shall update the language of
the notice provided under Section 20 of the Earned Income Tax Credit
Information Act in the appropriate blanks to reflect the maximum earned
income tax credit and the maximum earnings to which that credit shall
apply, as determined by the federal government.
(Source: P.A. 89-507, eff. 7-1-97.)
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(305 ILCS 5/11-30) (from Ch. 23, par. 11-30)
Sec. 11-30.
(Repealed).
(Source: P.A. 87-860. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/11-31)
Sec. 11-31.
Recovery of amounts spent on child medical care.
The
Illinois Department may provide by rule for certification to the Comptroller of
amounts spent on child medical care. The purpose of the certification shall be
to intercept, to the extent necessary to reimburse the Illinois Department for
its costs, State income tax refunds and other payments due to any noncustodial
parent who
(i) is required by court or administrative order to provide insurance or other
coverage of the
cost of health care services for a child eligible for medical assistance under
this
Code and (ii) has received payment from a third party for the costs of those
services but has not used the payments to reimburse either the other parent or
the guardian of the child or the provider of the services.
The rule shall provide for notice to the person and an opportunity to be
heard. A final administrative decision rendered by the Illinois Department
under this Section may
be reviewed only under the Administrative Review Law.
(Source: P.A. 89-183, eff. 1-1-96.)
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(305 ILCS 5/11-32) Sec. 11-32. Premium debts; forgiveness, compromise, reduction. The Department may forgive, compromise, or reduce any debt owed by a former or current recipient of medical assistance under this Code or health care benefits under the Children's Health Insurance Program or the Covering ALL KIDS Health Insurance Program that is related to any premium that was determined or imposed in accordance with (i) the Children's Health Insurance Program Act or the Covering ALL KIDS Health Insurance Act prior to those Acts becoming inoperative or (ii) any corresponding administrative rule.
(Source: P.A. 102-43, eff. 7-6-21.) |
(305 ILCS 5/Art. XII heading) ARTICLE XII.
ADMINISTRATION
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(305 ILCS 5/12-1) (from Ch. 23, par. 12-1)
Sec. 12-1. Administration of Code; Department of Healthcare and Family Services.
(a) This Code shall be administered by the Department of Human
Services and the Department of Healthcare and Family Services (formerly Illinois Department of Public
Aid)
as provided in the Department of Human Services Act.
(b) The Department of Healthcare and Family Services shall be under the supervision and
direction of the
Director of Healthcare and Family Services, as provided in Section 5-20 of the
Departments of State Government Law (20 ILCS 5/5-20). The Director shall be appointed pursuant
to the
provisions of Section 5-605 and meet the qualifications of Section
5-230 of
that Law.
The Assistant Director of Healthcare and Family Services, created by Section 5-165
of the
Departments of State Government Law (20 ILCS 5/5-165), shall be appointed pursuant to the
provisions
of Section 5-605 of that Law and shall meet the
qualifications
prescribed in
Section 5-230 of that Law.
The salaries of the Director and the Assistant Director shall be those
specified in Section 5-395 of the Departments of State
Government Law (20 ILCS 5/5-395).
The Department of Healthcare and Family Services and the Director of Healthcare and Family Services
shall comply with
other provisions of the Civil Administrative Code of Illinois which are
generally
applicable to the several departments of the State Government created by
that Code.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/12-2) (from Ch. 23, par. 12-2)
Sec. 12-2.
County departments.
The County Departments, under the supervision
and direction of the Illinois
Department and subject to its rules and regulations, shall locally
administer the programs
provided by Articles III, IV, and V of this Code
and shall provide the social services and utilize the rehabilitative
facilities authorized in Articles IX and IXA in respect to
persons served through
Articles III, IV, and V. They shall also
discharge such other duties as may be required by other provisions of
this Code or other laws of this State.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-3) (from Ch. 23, par. 12-3)
Sec. 12-3.
Local governmental units.
As provided in Article VI, local
governmental units shall provide funds for and administer the programs
provided in that Article subject, where so provided, to the supervision of
the Illinois Department. Local governmental units shall also provide the
social services and utilize the rehabilitative facilities authorized in
Article IX for persons served through Article VI, and shall discharge such
other duties as may be required by this Code or other laws of this State.
In counties not under township organization, the county shall provide
funds for and administer such programs.
In counties under township organization (including any such counties
in which the governing authority is a board of commissioners) the
various towns other than those towns lying entirely within the corporate
limits of any city, village or incorporated town having a population of
more than 500,000 inhabitants shall provide funds for and administer
such programs.
Cities, villages, and incorporated towns having a population of more
than 500,000 inhabitants shall provide funds for public aid purposes
under Article VI but the Department of Human Services shall administer the
program for such municipality.
For the fiscal year beginning July 1, 2003, however, the municipality shall
decrease by $5,000,000 the amount of funds it provides for public aid purposes
under Article VI. For each fiscal year thereafter, the municipality shall
decrease the amount of funds it provides for public aid purposes under Article
VI in that fiscal year by an additional amount equal to (i) $5,000,000 or (ii)
the amount provided by the municipality in the preceding fiscal year, whichever
is less, until the municipality does not provide any funds for public aid
purposes under Article VI.
Incorporated towns which have superseded civil townships shall
provide funds for and administer the public aid program provided by
Article VI.
In counties of less than 3 million population having a County
Veterans Assistance Commission in which there has been levied a tax as
authorized by Section 5-2006 of the Counties Code for the purpose of
providing assistance to military veterans and their families, the
County Veterans Assistance Commission shall administer the programs
provided by Article VI for such military veterans and their families
as seek aid through the County Veterans Assistance Commission.
(Source: P.A. 92-111, eff. 1-1-02; 92-597, eff. 6-28-02.)
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(305 ILCS 5/12-3.1) Sec. 12-3.1. Discontinuance of a coterminous township. Upon discontinuance of a coterminous township under Articles 27 and 28 of the Township Code, the coterminous municipality shall provide funds for and administer the public aid program provided for under Article VI of this Code.
(Source: P.A. 98-127, eff. 8-2-13; 99-474, eff. 8-27-15.) |
(305 ILCS 5/12-4) (from Ch. 23, par. 12-4)
Sec. 12-4.
Powers and duties of the Illinois department.
In addition to the powers, duties and functions vested in it by other
provisions of this Code or by other laws of this State, the Illinois
Department shall have the powers enumerated in Sections 12-4.1 to
12-4.30, inclusive, subject to the conditions therein stated.
(Source: P.A. 85-1209.)
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(305 ILCS 5/12-4.1) (from Ch. 23, par. 12-4.1)
Sec. 12-4.1.
Appointment of administrative staff.
Appoint, in accordance with the "Personnel Code", approved July 18,
1955, as amended, such administrative staff as may be necessary. The
enactment of this Code shall not impair the merit services status of
persons employed by the Illinois Department on the effective date thereof.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.3) (from Ch. 23, par. 12-4.3)
Sec. 12-4.3.
Child and Spouse Support Unit.)
Establish within the administrative staff a Child and Spouse Support unit, as provided
in Section 10-3.1 of Article X.
(Source: P.A. 79-474.)
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(305 ILCS 5/12-4.4) (from Ch. 23, par. 12-4.4)
Sec. 12-4.4. Administration of federally-aided programs. Direct
County Departments of Public Aid in the administration of
the federally
funded Supplemental Nutrition Assistance (SNAP) Program, programs to aid refugees and Articles III,
IV, and V of this Code.
The
Illinois Department of Human Services
shall operate a SNAP Employment and Training (SNAP E&T) program in
compliance with federal law. The SNAP E&T program may only be mandatory in counties where the Department can show that there are sufficient program slots for at least the majority of the county's current non-exempt work registrants as described in Section 11-20 of this Code. Nothing in this Section shall prevent the Department from operating a fully voluntary SNAP E&T program. The SNAP E&T program will have an Earnfare
component. The Earnfare component shall be available in selected geographic
areas based on criteria established by the Illinois Department of Human
Services by rule.
Participants in Earnfare will, to the extent resources allow, earn their
assistance. Participation in the Earnfare program is voluntary, except when
ordered by a court of competent jurisdiction. Eligibility for Earnfare may
be limited to only 6 months out of any 12 consecutive month period. Clients are
not entitled to be placed in an Earnfare slot. Earnfare slots shall be made
available only as resources permit. Earnfare shall be available to persons
receiving SNAP benefits who meet eligibility criteria established by the Illinois
Department of Human Services by rule.
The Illinois Department may, by rule, extend the Earnfare Program to clients
who do not receive SNAP benefits.
Receipt of SNAP benefits is not an
eligibility requirement of
Earnfare when a court of competent jurisdiction orders an individual to
participate in the Earnfare Program. To
the extent resources permit, the Earnfare program will allow participants
to engage in work-related activities to earn monthly financial assistance
payments and to improve participants' employability in order for them to
succeed in obtaining employment. The Illinois Department of Human Services may enter into
contracts with other public agencies including State agencies, with local
governmental units, and with not-for-profit community based organizations
to carry out the elements of the Program that the Department of Human Services deems appropriate.
The Earnfare Program shall contain the following elements:
(1) To the extent resources allow and slots exist, | ||
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(2) Persons participating in Earnfare shall engage in | ||
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(3) To the extent appropriate slots are available, | ||
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(4) The Department of Human Services shall consider | ||
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(5) The Department of Human Services may enter into | ||
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(6) To the extent resources permit, the Department of | ||
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(7) All income and asset limitations of the Federal | ||
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(8) Earnfare participants shall not displace or | ||
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(9) Persons who fail to cooperate with the SNAP E&T | ||
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(Source: P.A. 101-566, eff. 8-23-19.)
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(305 ILCS 5/12-4.5) (from Ch. 23, par. 12-4.5)
Sec. 12-4.5. Co-operation with Federal Government. Co-operate with the Federal Department of Health and Human Services,
or with any successor agency thereof, or with any other agency of
the Federal Government providing federal funds, commodities, or aid, for
public aid and other purposes, in any reasonable manner not contrary to
this Code, as may be necessary to qualify for federal aid for the several
public aid and welfare service programs established under this Code,
including the costs of administration and personnel training incurred
thereunder, and for such other aid, welfare and related programs for which
federal aid may be available.
The Department of Human Services may supervise the administration of food
and shelter
assistance under this Section for which the Department of Human Services is
authorized to
receive funds from federal, State and private sources. Under such terms as
the Department of Human Services may establish, such monies may be
distributed to units of
local government and non-profit agencies for the purpose of provision of
temporary shelter and food assistance. Temporary shelter means
emergency and transitional living arrangements, including related
ancillary services. Allowable costs shall include remodeling costs but
shall not include other costs not directly related to direct service
provision.
The Department of Human Services may provide low income families and individuals appropriate
supportive services on site to enhance their ability to maintain independent
living arrangements or may contract for the provision of those services on site
with entities that develop or operate housing developments, governmental units,
community based organizations, or not for profit organizations. Those living
arrangements may include transitional housing, single-room occupancy (SRO)
housing developments, or family housing developments. Supportive services may
include any service authorized under this Code including, but not
limited to, services relating to substance abuse, mental health,
transportation, child care, or case management. When appropriate, the
Department of Human Services shall work with other State agencies in order to coordinate services
and to maximize funding. The
Department of Human Services shall give priority for services to residents
of housing
developments
which have been funded by or have a commitment of funds from the Illinois
Housing Development Authority.
The Department of Human Services shall promulgate specific rules
governing the
selection of Distribution Network Agencies under the Federal Surplus
Commodity Program including, but not limited to, policies relative to the
termination of contracts, policies relative to fraud and abuse, appeals
processes, and information relative to application and selection processes.
The Department of Human Services shall also promulgate specific rules that set forth the
information required to be contained in the cost reports to be submitted by
each Distribution Network Agency to the Department of Human Services.
The Department of Human Services shall cooperate with units of local government and
non-profit agencies in the development and implementation of plans to
assure the availability of temporary shelter for persons without a home and/or
food assistance.
The Department of Human Services shall report annually to the House and Senate
Appropriations Committees of the General Assembly regarding the provision
of monies for such assistance as provided in this Section, including the
number of persons served, the level and cost of food provided and the level
and cost of each type of shelter provided and any unmet need as to food and
shelter.
The Illinois Department of Human Services shall make such
reports to the Federal Department or other Federal agencies in such form
and containing such information as may be required, and shall comply with
such provisions as may be necessary to assure the correctness and
verification of such reports if funds are contributed by the Federal
Government. In cooperating with any federal agency providing federal funds,
commodities, or aid for public aid and other purposes, the Department of
Human Services,
with the consent of the Governor, may make necessary expenditures from
moneys appropriated for such purposes for any of the subdivisions of
public aid, for related purposes, or for administration.
(Source: P.A. 97-333, eff. 8-12-11.)
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(305 ILCS 5/12-4.6) (from Ch. 23, par. 12-4.6)
Sec. 12-4.6.
Receipt and use of federal funds, commodities, or other aid.
Receive, expend and use for all purposes of this Code, and for other
public aid, welfare and related purposes, funds, commodities and other aid
made available by the Federal Government.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.7) (from Ch. 23, par. 12-4.7)
Sec. 12-4.7. Co-operation with other agencies. Make use of, aid and
co-operate with State and local governmental agencies, and co-operate with and
assist other governmental and private agencies and organizations engaged in
welfare functions.
This grant of authority includes the powers necessary for the Department of Healthcare and Family Services to administer the Illinois Health and Human Services Innovation Incubator (HHSi2) project. The Department of Healthcare and Family Services shall cochair with the Governor's Office of Management and Budget an Executive Steering Committee of partner State agencies to coordinate the HHSi2 project. The powers and duties of the Executive Steering Committee shall be established by intergovernmental agreement. In addition, the Department of Healthcare and Family Services is authorized, without limitation, to enter into agreements with federal agencies, to create and implement the HHSi2 Shared Interoperability Platform, and to create all Implementation Advance Planning documents for the HHSi2 project. (Source: P.A. 103-8, eff. 7-1-23.)
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(305 ILCS 5/12-4.7a) (from Ch. 23, par. 12-4.7a)
Sec. 12-4.7a.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
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(305 ILCS 5/12-4.7b)
(Text of Section before amendment by P.A. 103-688)
Sec. 12-4.7b. Exchanges of information; inmates. The Department shall enter
into intergovernmental agreements
to conduct monthly exchanges of information with
the
Illinois Department of Corrections, the Cook County Department of
Corrections, and the office of the sheriff of every other
county to determine whether any individual included in an assistance unit
receiving public aid
under any Article of this Code is an
inmate in a facility operated by the Illinois Department of Corrections, the
Cook County Department of
Corrections, or a county sheriff. The Illinois Department of Corrections, the Cook County Department of Corrections, and the office of the sheriff of every other county shall honor all intergovernmental agreements with the Department under this Section and shall provide all required information in a timely manner. The Department shall review each month
the entire list of individuals generated by the
monthly exchange and shall verify the eligibility for benefits under this
Code for each individual on the list. The Department shall terminate benefits
under this Code
for any individual determined to be ineligible by this monthly review.
The Department shall use any legal means available to recoup as an overpayment
any assistance
provided to an individual for any period during which he or she was ineligible
to receive the
assistance.
(Source: P.A. 101-115, eff. 7-22-19.)
(Text of Section after amendment by P.A. 103-688) Sec. 12-4.7b. Exchanges of information; inmates. The Department shall enter into intergovernmental agreements to conduct exchanges of information with the Illinois Department of Corrections, the Cook County Department of Corrections, and the office of the sheriff to the extent available to determine whether any individual included in an assistance unit receiving public aid under any Article of this Code is an inmate in a facility operated by the Illinois Department of Corrections, the Cook County Department of Corrections, or a county sheriff. Alternatively, the Department may utilize the option of purchasing incarceration data through a third-party resource in order to conduct data matches of incarcerated individuals. The Illinois Department of Corrections, the Cook County Department of Corrections, and the office of the sheriff of every other county shall honor all intergovernmental agreements with the Department under this Section and shall provide all required information in a timely manner. The Department shall review each individual prior to authorizing benefits at application and redetermination to verify eligibility for benefits under this Code. The Department shall terminate benefits under this Code for any individual determined to be ineligible by this review. The Department shall use any legal means available to recoup as an overpayment any assistance provided to an individual for any period during which he or she was ineligible to receive the assistance.(Source: P.A. 103-688, eff. 1-1-25.) |
(305 ILCS 5/12-4.7c)
Sec. 12-4.7c. Exchange of information after July 1, 1997.
(a) The Department of Human Services shall exchange with the
Department of Healthcare and Family Services information
that may be necessary for the enforcement of child support orders
entered pursuant to Sections 10-10 and 10-11 of this Code or pursuant to
the Illinois Marriage and Dissolution of Marriage Act, the Non-Support
of Spouse and Children Act, the Non-Support Punishment Act, the Revised
Uniform Reciprocal Enforcement of
Support Act, the Uniform Interstate Family Support Act,
the Illinois Parentage Act of 1984, or the Illinois Parentage Act of 2015.
(b) Notwithstanding any provisions in this Code to the contrary,
the Department of Human Services shall not be liable
to any person for any disclosure of information to the
Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) under subsection (a)
or for any other
action taken in good faith to comply with the requirements of subsection
(a).
(Source: P.A. 99-85, eff. 1-1-16.)
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(305 ILCS 5/12-4.7d)
Sec. 12-4.7d.
Interagency agreement regarding investigation of child care
providers. The Department shall enter into a written agreement with the
Department of Children and Family Services which shall provide for interagency
procedures regarding requests by the Department that the Department of Children
and Family Services conduct an investigation of the Central Register, as
defined in the Abused and Neglected Child Reporting Act, to ascertain if a
child care provider who is not required to be licensed
under the Child Care Act of 1969 and who is participating in the child care
assistance program under this Code has been determined to be a perpetrator in
an indicated report of child abuse or neglect.
(Source: P.A. 90-684, eff. 7-31-98.)
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(305 ILCS 5/12-4.7e) Sec. 12-4.7e. (Repealed).
(Source: P.A. 96-878, eff. 2-2-10. Repealed internally, eff. 1-1-12.) |
(305 ILCS 5/12-4.7f) Sec. 12-4.7f. Death records information. At least once each calendar month, the Department of Human Services shall cross-reference its roster of public aid recipients with the death records information from the Department of Public Health residing on the Electronic Data Warehouse at the Department of Healthcare and Family Services. A public aid recipient who is found to have a death record shall be subject to an immediate cancelation of his or her public aid benefits, including the deactivation of his or her LINK card, in instances where there are no other individuals receiving benefits in that assistance unit and upon
certification that the identity of the public aid recipient matches the identity
of the person named in the death certificate. As used in this Section, "LINK
card" means the electronic benefits transfer card issued by the Department of Human Services for the purpose of enabling a user of the card to obtain Supplemental Nutrition Assistance Program (SNAP) benefits or cash.
(Source: P.A. 99-87, eff. 7-21-15.) |
(305 ILCS 5/12-4.8) (from Ch. 23, par. 12-4.8)
Sec. 12-4.8.
Supervision of administration of general assistance.
Supervise
the administration of
General Assistance under Article VI by local governmental units
receiving State funds for the purposes of such Article.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-4.8a)
Sec. 12-4.8a.
General assistance record keeping.
The
Illinois Department shall establish procedures
designed to ensure that a person who receives a general assistance grant from
the Illinois Department does not receive a duplicate grant from a township
general assistance program that receives State funds.
(Source: P.A. 88-412.)
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(305 ILCS 5/12-4.9) (from Ch. 23, par. 12-4.9)
Sec. 12-4.9.
Hearings and investigations.
Conduct hearings and investigations in connection with the
administration of public aid; compel by subpoena, the attendance and
testimony of witnesses and the production of books and papers; and
administer oaths to witnesses. No person shall be compelled to attend an
investigation or hearing at a place outside the county in which he resides.
Subpoenas may be served as provided for in civil actions. The fees of
witnesses for attendance and travel shall be the same as the fees of
witnesses before the Circuit Court and shall be paid as an expense of
administration.
Any qualified officer or employee of the Department designated in
writing by the Director may conduct the hearings and investigations.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.10) (from Ch. 23, par. 12-4.10)
Sec. 12-4.10.
Forms and supplies.
Prescribe the form of and print and supply to the County Departments and
local governmental units official blanks for applications and reports and
such other forms as it deems advisable in relation to the administration of
public aid.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.11) (from Ch. 23, par. 12-4.11)
Sec. 12-4.11. Grant amounts. The Department,
with due regard for and subject to budgetary limitations, shall establish
grant amounts for each of the programs, by regulation. The grant amounts may
vary by program, size of assistance unit and geographic area. Grant amounts under the Temporary Assistance for Needy Families (TANF) program may not vary on the basis of a TANF recipient's county of residence.
Aid payments shall not be reduced except: (1) for changes in the cost of
items included in the grant amounts, or (2) for changes in the expenses of the
recipient, or (3) for changes in the income or resources available to the
recipient, or (4) for changes in grants resulting from adoption of a
consolidated grant amount.
The maximum benefit levels provided to TANF recipients shall increase as follows: beginning October 1, 2023, the Department of Human Services shall increase TANF grant amounts in effect on September 30, 2023 to at least 35% of the most recent United States Department of Health and Human Services Federal Poverty Guidelines for each family size. Beginning October 1, 2024, and each October 1 thereafter, the maximum benefit levels shall be annually adjusted to remain equal to at least 35% of the most recent poverty guidelines updated periodically in the Federal Register by the U.S. Department
of Health and Human Services under the authority of 42 U.S.C. 9902(2) for each family size. TANF grants for child-only assistance units shall be at least 75% of TANF grants for assistance units of the same size that consist of a caretaker relative with children. In fixing standards to govern payments or reimbursements for funeral
and burial expenses, the Department shall establish a minimum allowable
amount of
not less than
$1,000 for Department payment of funeral services and not less than $500 for
Department payment of burial or cremation services. On January 1, 2006, July 1, 2006, and July 1, 2007, the Department shall increase the minimum reimbursement amount for funeral and burial expenses under this Section by a percentage equal to the percentage increase in the Consumer Price Index for All Urban Consumers, if any, during the 12 months immediately preceding that January 1 or July 1. In establishing the minimum
allowable
amount, the Department shall take into account the services
essential to a dignified, low-cost (i) funeral and (ii) burial or
cremation, including reasonable
amounts that may be necessary for
burial space and cemetery charges, and any applicable taxes or other
required governmental fees or charges. If no
person has agreed to pay the total cost of the (i) funeral and
(ii) burial or cremation
charges, the Department shall pay the vendor the actual costs of the (i)
funeral
and
(ii) burial or cremation, or the minimum allowable amount for each service as
established by
the Department, whichever is less, provided that the Department reduces its
payments by
the amount available from the following sources: the decedent's assets
and
available resources and the anticipated amounts of any death benefits available
to the
decedent's estate, and amounts paid and arranged to be paid by the
decedent's legally
responsible relatives. A legally responsible relative is expected to pay
(i) funeral and (ii) burial
or cremation expenses unless financially unable to do so.
Nothing contained in this Section or in any other Section of this
Code shall be construed to prohibit the Illinois Department (1) from
consolidating existing standards on the basis of any standards which are
or were in effect on, or subsequent to July 1, 1969, or (2) from
employing any consolidated standards in determining need for public
aid and the amount of money payment or grant for individual recipients
or recipient families.
(Source: P.A. 103-8, eff. 6-7-23.)
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(305 ILCS 5/12-4.11-5) Sec. 12-4.11-5. Murdered Children Funeral and Burial Assistance Program. The Department of Human Services shall by rule administer the Murdered Children Funeral and Burial Assistance Program. Eligibility for the Murdered Children Funeral and Burial Assistance Program shall be limited to those individuals as described in the Murdered Children Funeral and Burial Assistance Act. Beginning July 1, 2023, the Department of Human Services shall make eligibility determinations for the Murdered Children Funeral and Burial Assistance Program and, subject to appropriation, shall make disbursements for eligible cases to a funeral establishment or cemetery authority as provided under the Murdered Children Funeral and Burial Assistance Act.
(Source: P.A. 102-754, eff. 5-10-22.) |
(305 ILCS 5/12-4.12) (from Ch. 23, par. 12-4.12)
Sec. 12-4.12.
Insurance Policies in Determination of Need.
To the extent authorized by the rules and regulations of the Illinois
Department, all or a portion of the loan or cash value of insurance
policies may be disregarded in the determination of need under Sections
3-1.2, 4-1.6, 5-4, 6-1.2 and 7-1.2. The Department may also provide, by
rule, (1) for the continuation of life insurance policies at face, cash, or
loan value amounts in excess of funeral and burial expenses, as such
expenses are governed by standards established under Section 12-4.11, and
(2) whether or not provision for continuation is made under (1), for the
taking of assignments of life insurance policies to cover an amount not in
excess of the amount of financial aid which has been, or may be, provided.
In making the determination under (1), the Department shall consider the
physical condition of the insured, the needs of the insured and his
dependents for financial aid, whether those needs will be of a temporary or
continuing nature, and the existence of any unusual circumstances which may
warrant a decision to permit such continuation.
(Source: P.A. 76-1416.)
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(305 ILCS 5/12-4.13) (from Ch. 23, par. 12-4.13)
Sec. 12-4.13.
Extension of federal commodity and food stamp programs to
non-recipients; Standards of eligibility. The Department of Human
Services shall provide, by rule, for the
extension of Federal surplus foods, food
stamps, or other commodities made available by the Federal Government to
persons who are not recipients of public aid, and establish standards for
determining the eligibility of such persons.
(Source: P.A. 89-507, eff. 7-1-97.)
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(305 ILCS 5/12-4.13a) Sec. 12-4.13a. Gross income eligibility standard; SNAP. Subject to federal approval if required, a household that includes an elderly, blind, or disabled person shall be considered categorically eligible for Supplemental Nutrition Assistance Program (SNAP) benefits if the gross income of such household is at or below 200% of the nonfarm income poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and
Human Services under the authority of 42 U.S.C. 9902(2); and a household that does not include an elderly, blind, or disabled person shall be considered categorically eligible for Supplemental Nutrition Assistance Program (SNAP) benefits if the gross income of such household is at or below 165% of those nonfarm income poverty guidelines.
(Source: P.A. 99-170, eff. 1-1-16.) |
(305 ILCS 5/12-4.13b) Sec. 12-4.13b. College student eligibility for supplemental nutrition assistance benefits. (a) For the purposes of Section 273.5(b)(11)(ii) of Title 7 of the Code of Federal Regulations, a career and technical educational program offered at a community college and approved by the Illinois Community College Board that could be a component of a SNAP Employment and Training (E&T) program, as identified by the Department of Human Services, shall be considered an employment and training program under Section 273.7 of Title 7 of the Code of Federal Regulations, unless prohibited by federal law. (b) The Department of Human Services, in consultation with representatives of the Illinois Community College Board, the Illinois Student Assistance Commission, the Illinois Workforce Innovation Board, and advocates for students and SNAP recipients, shall establish a protocol to identify and verify all potential exemptions to the eligibility rule described in Section 273.5(a) of Title 7 of the Code of Federal Regulations, and to identify and verify a student's participation in educational programs, including, but not limited to, self-initiated placements, that would exempt a student from the eligibility rule described in Section 273.5(a) of Title 7 of the Code of Federal Regulations. To the extent possible, this consultation shall take place through existing workgroups convened by the Department of Human Services. (c) If the United States Department of Agriculture requires federal approval of the exemption designation established pursuant to subsection (a) and the protocol established pursuant to subsection (b), the Department of Human Services shall seek and obtain that approval before publishing the guidance or regulation required by subsection (e). (d)(1) This Section does not require the Department of Human Services to offer a particular component, support services, or workers' compensation to a college student found eligible for an exemption pursuant to this Section. (2) This Section does not restrict or require the use of federal funds for the financing of SNAP E&T programs. (3) This Section does not require an institution of higher education to verify eligibility for SNAP. (e) The Department of Human Services shall adopt any rules necessary to implement the provisions of subsections (a), (b), (c), and (d).
(Source: P.A. 100-620, eff. 7-20-18; 101-560, eff. 8-23-19.) |
(305 ILCS 5/12-4.13c) Sec. 12-4.13c. SNAP Restaurant Meals Program. (a) Subject to federal approval of the plan for operating the Program, the Department of Human Services shall establish a Restaurant Meals Program as part of the federal Supplemental Nutrition Assistance Program (SNAP). Under the Restaurant Meals Program, households containing elderly or disabled members, and their spouses, as defined in 7 U.S.C. 2012(j), or homeless individuals, as defined in 7 U.S.C. 2012(l), shall have the option in accordance with 7 U.S.C. 2012(k) to redeem their SNAP benefits at private establishments that contract with the Department to offer meals for eligible individuals at concessional prices subject to 7 U.S.C. 2018(h). The Restaurant Meals Program shall be operational no later than July 1, 2021. (b) The Department of Human Services shall adopt any rules necessary to implement the provisions of this Section.
(Source: P.A. 101-10, eff. 6-5-19; 101-110, eff. 7-19-19; 102-558, eff. 8-20-21.) |
(305 ILCS 5/12-4.13d)
Sec. 12-4.13d. SNAP eligibility notification; college students. (a) To complement student financial assistance programs and to enhance their effectiveness for students with financial need, the Illinois Student Assistance Commission (ISAC) shall annually include information about the Supplemental Nutrition Assistance Program (SNAP) in the language that schools are required to provide to students eligible for the Monetary Award Program grant. The language shall, at a minimum, direct students to information about college student eligibility criteria for SNAP, and it shall direct students to the Department of Human Services and to the Illinois Hunger Coalition's Hunger Hotline for additional information. (b) Illinois institutions of higher education that participate in the Monetary Award Program (MAP) shall provide the notice described in subsection (a) to all students who are enrolled, or who are accepted for enrollment and intending to enroll, and who have been identified by ISAC as MAP-eligible at the institution. If possible, the institution may designate a public benefits liaison or single point person to assist students in taking the necessary steps to obtain public benefits if eligible. (c) ISAC shall adopt any rules necessary to implement the provisions of this Section on or before October 1, 2020.
(Source: P.A. 101-560, eff. 8-23-19; 102-558, eff. 8-20-21.)
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(305 ILCS 5/12-4.13e) Sec. 12-4.13e. Summer EBT Program. (a) Subject to federal approval, the Department of Human Services may establish and participate in the federal Summer Electronic Benefit Transfer Program for Children, which may be referred to as the Summer EBT Program. (b) The Summer EBT Program Fund is established as a federal trust fund in the State treasury. The fund is established to receive moneys from the federal government for the Summer EBT Program. Subject to appropriation, moneys in the Summer EBT Program Fund shall be expended by the Department of Human Services only for those purposes permitted under the federal Summer Electronic Benefit Transfer Program for Children. (c) The Department of Human Services is authorized to adopt any rules, including emergency rules, necessary to implement the provisions of this Section.
(Source: P.A. 103-588, eff. 6-5-24.) |
(305 ILCS 5/12-4.14) (from Ch. 23, par. 12-4.14)
Sec. 12-4.14.
Investigation of resources of applicants, recipients, and responsible
relatives.
Investigate the financial condition of applicants, recipients, and
responsible relatives as defined in Section 2-11 of Article II, in order
to determine whether an applicant or recipient has or can obtain property,
income, resources, or other sources of support sufficient to provide him
with a standard of living compatible with health and well-being.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.15) (from Ch. 23, par. 12-4.15)
Sec. 12-4.15.
(Repealed).
(Source: P.A. 86-651. Repealed by P.A. 90-17, eff. 7-1-97.)
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(305 ILCS 5/12-4.16) (from Ch. 23, par. 12-4.16)
Sec. 12-4.16.
Economic and social investigations.
Investigate causes of dependency and economic distress, develop plans
and programs for the elimination and prevention of such causes, and
recommend the execution of such programs to appropriate agencies.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.17) (from Ch. 23, par. 12-4.17)
Sec. 12-4.17.
Training personnel for employment in public aid programs.
Establish within the administrative staff a staff development unit to
provide orientation and job-related training for new employees and
continued development and improvement of job skills of all staff of the
Department and County Departments; establish
criteria for and administer and maintain a program for granting employees
educational leave for specialized professional or technical study; and
co-ordinate such training, development, and educational activities with the
training program of the Illinois Department of Central Management Services
and with other
programs for training personnel established under this Section. The
Department may also make grants to public or other non-profit institutions
of higher learning for training personnel employed or preparing for
employment in the public aid programs and conduct special courses of study
or seminars for personnel by experts hired temporarily by the Illinois
Department.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-4.18) (from Ch. 23, par. 12-4.18)
Sec. 12-4.18.
Grants and gifts for public aid and related welfare purposes.
Accept, hold and administer in behalf of the State any grant, gift or legacy
of money, securities, or property to the Illinois
Department or to the State of Illinois for public aid or any related
welfare purpose.
From appropriations from the Assistance to the Homeless Fund, a special
fund in the State treasury, which is hereby created, provide grants to
not-for-profit organizations for the purpose of providing assistance to
homeless persons.
Grants, gifts, and legacies for employment and training programs for public
assistance clients shall be deposited into the Employment and Training Fund.
Grants, gifts, donations, and legacies for functions connected with the
administration of any medical program administered by the Illinois Department
shall be deposited into the Medical Special Purposes Trust
Fund created under Section 12-10.5.
(Source: P.A. 92-37, eff. 7-1-01.)
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(305 ILCS 5/12-4.19) (from Ch. 23, par. 12-4.19)
Sec. 12-4.19.
Grants for Pilot Studies and Research.
Co-operate with the Federal Government, private foundations, persons,
corporations or other entities making grants of funds or offering the
services of technical assistants for pilot studies and other research
programs relating to effective methods of rehabilitation or the adequacy of
public aid and welfare programs, policies and procedures, and accept, hold
and administer grants made in connection therewith.
Grants for functions connected with the administration of any medical program
administered by the Illinois Department shall be deposited into the
Medical Special Purposes Trust Fund created under Section 12-10.5.
(Source: P.A. 92-37, eff. 7-1-01.)
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(305 ILCS 5/12-4.20) (from Ch. 23, par. 12-4.20)
Sec. 12-4.20.
Appointment of statewide advisory committees.
Appoint, when and as it may deem necessary, statewide advisory
committees to provide professional or technical consultation in respect to
medical or dental or hospital care, general assistance, home economics, or
other special aspects of public aid and related welfare functions. The
members of the committees shall receive no compensation for their services,
other than expenses actually incurred in the performance of their official
duties. The number of members of each advisory committee shall be
determined by the Illinois Department. The committees shall consult with
and advise the Illinois Department in respect to problems and policies
incident to the administration of the particular Article or Articles of
this Code germane to their respective fields of competence.
The Illinois Department shall include a balanced representation of
recipients, service providers, representatives of community and welfare
advocacy groups, representatives of local governments dealing with public
aid, and representatives of the general public on all statewide advisory
committees appointed by it, except that Professional Advisory Committees created
under Section 5-5 of this Code to provide technical and
professional advice to the Department shall consist entirely of persons
practicing a particular profession.
(Source: P.A. 86-1475.)
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(305 ILCS 5/12-4.20a) (from Ch. 23, par. 12-4.20a)
Sec. 12-4.20a.
(Repealed).
(Source: P.A. 92-84, eff. 7-1-02. Repealed internally, eff. 7-1-02.)
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(305 ILCS 5/12-4.20b) (from Ch. 23, par. 12-4.20b)
Sec. 12-4.20b.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
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(305 ILCS 5/12-4.20c) (from Ch. 23, par. 12-4.20c)
Sec. 12-4.20c.
Appointment of Child Support Advisory Committee.
Appoint
the Child Support Advisory Committee to be composed of members of the
General Assembly, the judiciary, the private bar, and others with expertise
specific to child support establishment and enforcement. Among the tasks of
the Committee shall be the periodic review of the State's child support
guidelines as required by the federal Family Support Act of 1988. Members
shall be appointed for one year terms commencing on January 1 of each year.
Each newly appointed Committee shall elect a chairperson from among its
members. Members shall serve without compensation, but shall be reimbursed
for expenses incurred in the performance of their duties. The Committee
shall meet at least quarterly and at other times at the call of the
chairperson or at the request of the Director.
(Source: P.A. 86-1347; 86-1432.)
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(305 ILCS 5/12-4.20d) (from Ch. 23, par. 12-4.20d)
Sec. 12-4.20d.
Appointment of Social Services Advisory Council.
Appoint the Social Services Advisory Council, to be composed of 30
members, which shall include a balanced representation of recipients,
services providers, local governmental units, community and welfare
advocacy groups, academia and the general public. The Council shall advise
the Illinois Department regarding all aspects of assistance
delivered or contracted for under Articles III, IV, VI and IX of this Code
and other areas as deemed appropriate by the Director. In
appointing the first Council, the Director shall name 15 members to 2 year
terms and 15 members to 4 year terms, all of whom shall be appointed within
6 months of the effective date of this amendatory Act of 1991. All members
appointed thereafter shall serve 4 year terms. Members shall serve without
compensation other than reimbursement of expenses actually incurred in the
performance of their official duties. At its first meeting, the Council
shall select a chair from among its members. The Council shall meet at
least quarterly and at other times at the call of the chair.
(Source: P.A. 87-685.)
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(305 ILCS 5/12-4.21) (from Ch. 23, par. 12-4.21)
Sec. 12-4.21.
Appointment of county welfare services committee.
Appoint, in the manner provided in Section 12-19, the members of the
County Welfare Services Committee in each county of the State.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.22) (from Ch. 23, par. 12-4.22)
Sec. 12-4.22.
Utilization of volunteers.
Adopt, in cooperation with the County Welfare Services Committee of each
county, a plan for the recruitment and full utilization of volunteers to
assist caseworkers and other staff in the performance of their
responsibilities in administering the public aid programs.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.23) (from Ch. 23, par. 12-4.23)
Sec. 12-4.23.
Disposition of obsolete equipment and supplies.
Sell, destroy, or otherwise dispose of office equipment and supplies of
the Illinois Department or the County Departments which have become
worthless by reason of obsolescence or condition of disrepair. If the
Illinois Department orders the sale of all or any portion of such equipment
or supplies, such sale may be either public or private and for cash, and
the proceeds thereof shall be paid into the General Revenue Fund.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.24) (from Ch. 23, par. 12-4.24)
Sec. 12-4.24.
Reports and recommendations.
Recommend to the Governor and General Assembly the enactment of such
legislation as it may deem necessary to improve public aid administration
in this State; submit to the Governor and the General Assembly such reports
as may be requested or as it may deem necessary; and make such other
reports as may be required to supply necessary information concerning
problems and policies relating to the administration of the public aid
programs.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-4.24a) (from Ch. 23, par. 12-4.24a)
Sec. 12-4.24a. Report and recommendations concerning designated
shortage area. The Illinois Department shall analyze payments made to
providers of medical services under Article V of
this Code to
determine whether any special compensatory standard should be applied to
payments to such providers in designated shortage areas as defined in
Section 3.04 of the Underserved Health Care Provider Workforce Act. The Illinois Department shall, not later than June 30, 1990,
report to the Governor and the General Assembly concerning the results of
its analysis, and may provide by rule for adjustments in its payment rates
to medical service providers in such areas.
(Source: P.A. 101-118, eff. 7-22-19; 102-888, eff. 5-17-22.)
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(305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
Sec. 12-4.25. Medical assistance program; vendor participation.
(A) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation, association,
agency, institution or other legal entity to participate as a vendor of
goods or services to recipients under the medical assistance program
under Article V, or may exclude any such
person or entity from participation as such a vendor, and may
deny, suspend, or recover payments, if after reasonable notice and opportunity for a
hearing the Illinois Department finds:
(a) Such vendor is not complying with the | ||
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(b) Such vendor has failed to keep or make available | ||
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(c) Such vendor has failed to furnish any information | ||
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(d) Such vendor has knowingly made, or caused to be | ||
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(e) Such vendor has furnished goods or services to a | ||
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(f) The vendor; a person with management | ||
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(1) was previously terminated, suspended, or | ||
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(2) was a person with management responsibility | ||
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(3) was an officer, or person owning, either | ||
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(4) was an owner of a sole proprietorship or | ||
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(f-1) Such vendor has a delinquent debt owed to the | ||
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(g) The vendor; a person with management | ||
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(1) has engaged in practices prohibited by | ||
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(2) was a person with management responsibility | ||
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(3) was an officer, or person owning, either | ||
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(4) was an owner of a sole proprietorship or | ||
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(h) The direct or indirect ownership of the vendor | ||
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(A-5) The Illinois Department may deny, suspend, or terminate the
eligibility
of any person, firm, corporation, association, agency, institution, or other
legal entity to participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable
notice and opportunity for a hearing, the Illinois Department finds that the
vendor; a person with management responsibility for a vendor; an officer or
person owning, either directly or indirectly, 5% or more of the shares of stock
or other evidences of ownership in a corporate vendor; an owner of a sole
proprietorship that is a vendor; or a partner in a partnership that is a vendor
has been convicted of an offense based on fraud or willful
misrepresentation related to any of
the following:
(1) The medical assistance program under Article V of | ||
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(2) A medical assistance or health care program in | ||
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(3) The Medicare program under Title XVIII of the | ||
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(4) The provision of health care services.
(5) A violation of this Code, as provided in Article | ||
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(A-10) The Illinois Department may deny, suspend, or terminate the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a hearing, the Illinois Department finds that (i) the vendor, (ii) a person with management responsibility for a vendor, (iii) an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, (iv) an owner of a sole proprietorship that is a vendor, or (v) a partner in a partnership that is a vendor has been convicted of an offense related to any of the following:
(1) Murder.
(2) A Class X felony under the Criminal Code of 1961 | ||
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(3) Sexual misconduct that may subject recipients to | ||
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(4) A criminal offense that may subject recipients to | ||
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(5) A crime of fraud or dishonesty. (6) A crime involving a controlled substance. (7) A misdemeanor relating to fraud, theft, | ||
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(A-15) The Illinois Department may deny the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V if, after reasonable notice and opportunity for a hearing, the Illinois Department finds: (1) The applicant or any person with management | ||
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(2) The applicant or any person with management | ||
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(3) There is a credible allegation of the use, | ||
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(4) There is a credible allegation of a transfer of | ||
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(5) There is a credible allegation of the use, | ||
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(6) There is a credible allegation that the | ||
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As used in this subsection, "credible allegation" is defined to include an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the Illinois False Claims Act, and law enforcement investigations. An allegation is considered to be credible when it has indicia of reliability. (B) The Illinois Department shall deny, suspend or terminate the
eligibility of any person, firm, corporation, association, agency,
institution or other legal entity to participate as a vendor of goods or
services to recipients under the medical assistance program under
Article V, or may
exclude any such person or entity from participation as such a
vendor:
(1) immediately, if such vendor is not properly | ||
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(2) within 30 days of the date when such vendor's | ||
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(3) if such vendor has been convicted of a violation | ||
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(C) Upon termination, suspension, or exclusion of a vendor of goods or services from
participation in the medical assistance program authorized by this
Article, a person with management responsibility for such vendor during
the time of any conduct which served as the basis for that vendor's
termination, suspension, or exclusion is barred from participation in the medical assistance
program.
Upon termination, suspension, or exclusion of a corporate vendor, the officers and persons
owning, directly or indirectly, 5% or more of the shares of stock or
other evidences of ownership in the vendor during the time of any
conduct which served as the basis for that vendor's termination, suspension, or exclusion are
barred from participation in the medical assistance program. A person who
owns, directly or indirectly, 5% or more of the shares of stock or other
evidences of ownership in a terminated, suspended, or excluded vendor may not transfer his or
her ownership interest in that vendor to his or her spouse, child, brother,
sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or
relative by marriage.
Upon termination, suspension, or exclusion of a sole proprietorship or partnership, the owner
or partners during the time of any conduct which served as the basis for
that vendor's termination, suspension, or exclusion are barred from participation in the medical
assistance program. The owner of a terminated, suspended, or excluded vendor that is a sole
proprietorship, and a partner in a terminated, suspended, or excluded vendor that is a partnership, may
not transfer his or her ownership or partnership interest in that vendor to his
or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle,
aunt, niece, nephew, cousin, or relative by marriage.
A person who owns, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor who owes a debt to the Department, if that vendor has not made payment arrangements acceptable to the Department, shall not transfer his or her ownership interest in that vendor, or vendor assets of any kind, to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage. Rules adopted by the Illinois Department to implement these
provisions shall specifically include a definition of the term
"management responsibility" as used in this Section. Such definition
shall include, but not be limited to, typical job titles, and duties and
descriptions which will be considered as within the definition of
individuals with management responsibility for a provider.
A vendor or a prior vendor who has been terminated, excluded, or suspended from the medical assistance program, or from another state or federal medical assistance or health care program, and any individual currently or previously barred from the medical assistance program, or from another state or federal medical assistance or health care program, as a result of being an officer or a person owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor during the time of any conduct which served as the basis for that vendor's termination, suspension, or exclusion, may be required to post a surety bond as part of a condition of enrollment or participation in the medical assistance program. The Illinois Department shall establish, by rule, the criteria and requirements for determining when a surety bond must be posted and the value of the bond. A vendor or a prior vendor who has a debt owed to the Illinois Department and any individual currently or previously barred from the medical assistance program, or from another state or federal medical assistance or health care program, as a result of being an officer or a person owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in that corporate or limited liability company vendor during the time of any conduct which served as the basis for the debt, may be required to post a surety bond as part of a condition of enrollment or participation in the medical assistance program. The Illinois Department shall establish, by rule, the criteria and requirements for determining when a surety bond must be posted and the value of the bond. (D) If a vendor has been suspended from the medical assistance
program under Article V of the Code, the Director may require that such
vendor correct any deficiencies which served as the basis for the
suspension. The Director shall specify in the suspension order a specific
period of time, which shall not exceed one year from the date of the
order, during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension the Director
shall reinstate such vendor, unless he finds that such vendor has not
corrected deficiencies upon which the suspension was based.
If a vendor has been terminated, suspended, or excluded from the medical assistance program
under Article V, such vendor shall be barred from participation for at
least one year, except that if a vendor has been terminated, suspended, or excluded based on a
conviction of a
violation of Article VIIIA or a conviction of a felony based on fraud or a
willful misrepresentation related to (i) the medical assistance program under
Article V, (ii) a federal or another state's medical assistance or health care program, or (iii) the provision of health care services, then
the vendor shall be barred from participation for 5 years or for the length of
the vendor's sentence for that conviction, whichever is longer. At the end of
one year a vendor who has been terminated, suspended, or excluded
may apply for reinstatement to the program. Upon proper application to
be reinstated such vendor may be deemed eligible by the Director
providing that such vendor meets the requirements for eligibility under
this Code. If such vendor is deemed not eligible for
reinstatement, he
shall be barred from again applying for reinstatement for one year from the
date his application for reinstatement is denied.
A vendor whose termination, suspension, or exclusion from participation in the Illinois medical
assistance program under Article V was based solely on an action by a
governmental entity other than the Illinois Department may, upon reinstatement
by that governmental entity or upon reversal of the termination, suspension, or exclusion, apply for
rescission of the termination, suspension, or exclusion from participation in the Illinois medical
assistance program. Upon proper application for rescission, the vendor may be
deemed eligible by the Director if the vendor meets the requirements for
eligibility under this Code.
If a vendor has been terminated, suspended, or excluded and reinstated to the medical assistance
program under Article V and the vendor is terminated, suspended, or excluded a second or subsequent
time from the medical assistance program, the vendor shall be barred from
participation for at least 2 years, except that if a vendor has been
terminated, suspended, or excluded a second time based on a
conviction of a violation of Article VIIIA or a conviction of a felony based on
fraud or a willful misrepresentation related to (i) the medical assistance
program under Article V, (ii) a federal or another state's medical assistance or health care program, or (iii) the provision of health care
services, then the vendor shall be barred from participation for life. At
the end of 2 years, a vendor who has
been terminated, suspended, or excluded may apply for reinstatement to the program. Upon application
to be reinstated, the vendor may be deemed eligible if the vendor meets the
requirements for eligibility under this Code. If the vendor is deemed not
eligible for reinstatement, the vendor shall be barred from again applying for
reinstatement for 2 years from the date the vendor's application for
reinstatement is denied.
(E) The Illinois Department may recover money improperly or
erroneously paid, or overpayments, either by setoff, crediting against
future billings or by requiring direct repayment to the Illinois
Department. The Illinois Department may suspend or deny payment, in whole or in part, if such payment would be improper or erroneous or would otherwise result in overpayment. (1) Payments may be suspended, denied, or recovered | ||
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(2) Notwithstanding any other provision of law, if a | ||
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(E-5) Civil monetary penalties. (1) As used in this subsection (E-5): (a) "Knowingly" means that a person, with respect | ||
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(b) "Overpayment" means any funds that a person | ||
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(c) "Remuneration" means the offer or transfer of | ||
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(d) "Should know" means that a person, with | ||
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(2) Any person (including a vendor, provider, | ||
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(a) knowingly presents or causes to be presented | ||
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(i) is for a medical or other item or service | ||
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(ii) is for a medical or other item or | ||
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(iii) is presented for a vendor physician's | ||
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(AA) was not licensed as a physician; (BB) was licensed as a physician but such | ||
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(CC) represented to the patient at the | ||
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(iv) is for a medical or other item or | ||
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(v) is for a pattern of medical or other | ||
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(b) knowingly presents or causes to be presented | ||
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(c) knowingly gives or causes to be given to any | ||
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(d) in the case of a person who is not an | ||
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(i) retains a direct or indirect ownership or | ||
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(ii) is an officer or managing employee of | ||
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(e) offers or transfers remuneration to any | ||
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(f) arranges or contracts (by employment or | ||
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(g) commits an act described in subsection (b) or | ||
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(h) knowingly makes, uses, or causes to be made | ||
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(i) fails to grant timely access, upon reasonable | ||
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(j) orders or prescribes a medical or other item | ||
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(k) knowingly makes or causes to be made any | ||
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(l) knows of an overpayment and does not report | ||
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shall be subject, in addition to any other penalties that | ||
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(3) In addition, the Director or his or her designee | ||
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(4) The Illinois Department may seek the civil | ||
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(5) Any final order, decision, or other determination | ||
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(6)(a) If a person has received an overpayment, the | ||
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(i) report and return the overpayment to the | ||
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(ii) notify the Department in writing of the | ||
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(b) An overpayment must be reported and returned | ||
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(i) the date which is 60 days after the date on | ||
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(ii) the date any corresponding cost report is | ||
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(E-10) A vendor who disputes an overpayment identified as part of a Department audit shall utilize the Department's self-referral disclosure protocol as set forth under this Code to identify, investigate, and return to the Department any undisputed audit overpayment amount. Unless the disputed overpayment amount is subject to a fraud payment suspension, or involves a termination sanction, the Department shall defer the recovery of the disputed overpayment amount up to one year after the date of the Department's final audit determination, or earlier, or as required by State or federal law. If the administrative hearing extends beyond one year, and such delay was not caused by the request of the vendor, then the Department shall not recover the disputed overpayment amount until the date of the final administrative decision. If a final administrative decision establishes that the disputed overpayment amount is owed to the Department, then the amount shall be immediately due to the Department. The Department shall be entitled to recover interest from the vendor on the overpayment amount from the date of the overpayment through the date the vendor returns the overpayment to the Department at a rate not to exceed the Wall Street Journal Prime Rate, as published from time to time, but not to exceed 5%. Any interest billed by the Department shall be due immediately upon receipt of the Department's billing statement. (F) The Illinois Department may withhold payments to any vendor
or alternate payee prior to or during the pendency of any audit or proceeding under this Section, and through the pendency of any administrative appeal or administrative review by any court proceeding. The Illinois Department shall
state by rule with as much specificity as practicable the conditions
under which payments will not be withheld under this Section. Payments may be denied for bills
submitted with service dates occurring during the pendency of a
proceeding, after a final decision has been rendered, or after the conclusion of any administrative appeal, where the final administrative decision is to terminate, exclude, or suspend
eligibility to participate in the medical assistance program. The
Illinois Department shall state by rule with as much specificity as
practicable the conditions under which payments will not be denied for
such bills.
The Illinois
Department shall state by rule a process and criteria by
which a vendor or alternate payee may request full or partial release of payments withheld under
this subsection. The Department must complete a proceeding under this Section
in a timely manner.
Notwithstanding recovery allowed under subsection (E) or this subsection (F), the Illinois Department may withhold payments to any vendor or alternate payee who is not properly licensed, certified, or in compliance with State or federal agency regulations. Payments may be denied for bills submitted with service dates occurring during the period of time that a vendor is not properly licensed, certified, or in compliance with State or federal regulations. Facilities licensed under
the Nursing Home Care Act shall have payments denied or
withheld pursuant to subsection (I) of this Section. (F-5) The Illinois Department may temporarily withhold payments to
a vendor or alternate payee if any of the following individuals have been indicted or
otherwise charged under a law of the United States or this or any other state
with an offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to (i) the medical
assistance program under Article V of this Code, (ii) a federal or another state's medical assistance
or health care program, or (iii) the provision of health care services:
(1) If the vendor or alternate payee is a | ||
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(2) If the vendor is a sole proprietorship: the owner | ||
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(3) If the vendor or alternate payee is a | ||
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(4) If the vendor or alternate payee is any other | ||
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If the Illinois Department withholds payments to a vendor or alternate payee under this
subsection, the Department shall not release those payments to the vendor
or alternate payee
while any criminal proceeding related to the indictment or charge is pending
unless the Department determines that there is good cause to release the
payments before completion of the proceeding. If the indictment or charge
results in the individual's conviction, the Illinois Department shall retain
all withheld
payments, which shall be considered forfeited to the Department. If the
indictment or charge does not result in the individual's conviction, the
Illinois Department
shall release to the vendor or alternate payee all withheld payments.
(F-10) If the Illinois Department establishes that the vendor or alternate payee owes a debt to the Illinois Department, and the vendor or alternate payee subsequently fails to pay or make satisfactory payment arrangements with the Illinois Department for the debt owed, the Illinois Department may seek all remedies available under the law of this State to recover the debt, including, but not limited to, wage garnishment or the filing of claims or liens against the vendor or alternate payee. (F-15) Enforcement of judgment. (1) Any fine, recovery amount, other sanction, or | ||
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(2) After expiration of the period in which judicial | ||
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(3) In any case in which any person or entity has | ||
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(4) Upon being recorded in the manner required by | ||
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(5) The Director may set aside any judgment entered | ||
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(G) The provisions of the Administrative Review Law, as now or hereafter
amended, and the rules adopted pursuant
thereto, shall apply to and govern all proceedings for the judicial
review of final administrative decisions of the Illinois Department
under this Section. The term "administrative decision" is defined as in
Section 3-101 of the Code of Civil Procedure.
(G-5) Vendors who pose a risk of fraud, waste, abuse, or harm.
(1) Notwithstanding any other provision in this | ||
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(2) Vendors who pose a risk of fraud, waste, abuse, | ||
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(A) In the case of a vendor that is a | ||
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(B) In the case of a vendor that is a | ||
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(C) In the case of a vendor that is a sole | ||
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(D) Each officer or manager of the vendor.
Each such vendor shall be responsible for payment of | ||
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(3) Vendors who pose a risk of fraud, waste, abuse, | ||
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(4) The Department, or its agents, may refuse to | ||
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(A) the Department has initiated a notice of | ||
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(B) the Department has issued notification of its | ||
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(C) the Department has issued a notification of | ||
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(5) As used in this subsection, the following terms | ||
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(A) "Fraud" means an intentional deception or | ||
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(B) "Abuse" means provider practices that are | ||
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(C) "Waste" means the unintentional misuse of | ||
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(D) "Harm" means physical, mental, or monetary | ||
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(G-6) The Illinois Department, upon making a determination based upon information in the possession of the Illinois Department that continuation of participation in the medical assistance program by a vendor would constitute an immediate danger to the public, may immediately suspend such vendor's participation in the medical assistance program without a hearing. In instances in which the Illinois Department immediately suspends the medical assistance program participation of a vendor under this Section, a hearing upon the vendor's participation must be convened by the Illinois Department within 15 days after such suspension and completed without appreciable delay. Such hearing shall be held to determine whether to recommend to the Director that the vendor's medical assistance program participation be denied, terminated, suspended, placed on provisional status, or reinstated. In the hearing, any evidence relevant to the vendor constituting an immediate danger to the public may be introduced against such vendor; provided, however, that the vendor, or his or her counsel, shall have the opportunity to discredit, impeach, and submit evidence rebutting such evidence. (H) Nothing contained in this Code shall in any way limit or
otherwise impair the authority or power of any State agency responsible
for licensing of vendors.
(I) Based on a finding of noncompliance on the part of a nursing home with
any requirement for certification under Title XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department may impose one or more of the following remedies after
notice to the facility:
(1) Termination of the provider agreement.
(2) Temporary management.
(3) Denial of payment for new admissions.
(4) Civil money penalties.
(5) Closure of the facility in emergency situations | ||
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(6) State monitoring.
(7) Denial of all payments when the U.S. Department | ||
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The Illinois Department shall by rule establish criteria governing continued
payments to a nursing facility subsequent to termination of the facility's
provider agreement if, in the sole discretion of the Illinois Department,
circumstances affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois Department may
condition those continued payments on the appointment of temporary management,
sale of the facility to new owners or operators, or other
arrangements that the Illinois Department determines best serve the needs of
the facility's residents.
Except in the case of a facility that has a right to a hearing on the finding
of noncompliance before an agency of the federal government, a facility may
request a hearing before a State agency on any finding of noncompliance within
60 days after the notice of the intent to impose a remedy. Except in the case
of civil money penalties, a request for a hearing shall not delay imposition of
the penalty. The choice of remedies is not appealable at a hearing. The level
of noncompliance may be challenged only in the case of a civil money penalty.
The Illinois Department shall provide by rule for the State agency that will
conduct the evidentiary hearings.
The Illinois Department may collect interest on unpaid civil money penalties.
The Illinois Department may adopt all rules necessary to implement this
subsection (I).
(J) The Illinois Department, by rule, may permit individual practitioners to designate that Department payments that may be due the practitioner be made to an alternate payee or alternate payees. (a) Such alternate payee or alternate payees shall be | ||
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(b) If a practitioner designates an alternate payee, | ||
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(c) Registration as an alternate payee or alternate | ||
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(d) The Illinois Department may seek a revocation of | ||
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(1) the alternate payee is not complying with the | ||
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(2) the alternate payee has failed to keep or | ||
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(3) the alternate payee has failed to furnish any | ||
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(4) the alternate payee has knowingly made, or | ||
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(5) the alternate payee, a person with management | ||
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(a) was previously terminated, suspended, or | ||
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(b) was a person with management | ||
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(c) was an officer, or person owning, either | ||
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(d) was an owner of a sole proprietorship or | ||
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(6) the alternate payee, a person with management | ||
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(a) has engaged in conduct prohibited by | ||
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(b) was a person with management | ||
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(c) was an officer, or person owning, either | ||
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(d) was an owner of a sole proprietorship or | ||
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(7) the direct or indirect ownership of the | ||
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(K) The Illinois Department of Healthcare and Family Services may withhold payments, in whole or in part, to a provider or alternate payee where there is credible evidence, received from State or federal law enforcement or federal oversight agencies or from the results of a preliminary Department audit, that the circumstances giving rise to the need for a withholding of payments may involve fraud or willful misrepresentation under the Illinois Medical Assistance program. The Department shall by rule define what constitutes "credible" evidence for purposes of this subsection. The Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold such payments. A provider or alternate payee may request a reconsideration of payment withholding, and the Department must grant such a request. The Department shall state by rule a process and criteria by which a provider or alternate payee may request full or partial release of payments withheld under this subsection. This request may be made at any time after the Department first withholds such payments. (a) The Illinois Department must send notice of its | ||
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(1) State that payments are being withheld in | ||
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(2) State that the withholding is for a temporary | ||
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(3) Specify, when appropriate, which type or | ||
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(4) Inform the provider or alternate payee of the | ||
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(5) Inform the provider or alternate payee that a | ||
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(b) All withholding-of-payment actions under this | ||
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(1) The Illinois Department or the prosecuting | ||
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(2) Legal proceedings related to the provider's | ||
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(3) The withholding of payments for a period of 3 | ||
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(c) The Illinois Department may adopt all rules | ||
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(K-5) The Illinois Department may withhold payments, in whole or in part, to a provider or alternate payee upon initiation of an audit, quality of care review, investigation when there is a credible allegation of fraud, or the provider or alternate payee demonstrating a clear failure to cooperate with the Illinois Department such that the circumstances give rise to the need for a withholding of payments. As used in this subsection, "credible allegation" is defined to include an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the Illinois False Claims Act, and law enforcement investigations. An allegation is considered to be credible when it has indicia of reliability. The Illinois Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold such payments. A provider or alternate payee may request a hearing or a reconsideration of payment withholding, and the Illinois Department must grant such a request. The Illinois Department shall state by rule a process and criteria by which a provider or alternate payee may request a hearing or a reconsideration for the full or partial release of payments withheld under this subsection. This request may be made at any time after the Illinois Department first withholds such payments. (a) The Illinois Department must send notice of its | ||
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(1) State that payments are being withheld in | ||
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(2) State that the withholding is for a temporary | ||
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(3) Specify, when appropriate, which type or | ||
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(4) Inform the provider or alternate payee of the | ||
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(5) Inform the provider or alternate payee that a | ||
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(b) All withholding of payment actions under this | ||
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(1) The Illinois Department determines that there | ||
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(2) The withholding of payments has lasted for a | ||
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(c) The Illinois Department may adopt all rules | ||
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(L) The Illinois Department shall establish a protocol to enable health care providers to disclose an actual or potential violation of this Section pursuant to a self-referral disclosure protocol, referred to in this subsection as "the protocol". The protocol shall include direction for health care providers on a specific person, official, or office to whom such disclosures shall be made. The Illinois Department shall post information on the protocol on the Illinois Department's public website. The Illinois Department may adopt rules necessary to implement this subsection (L). In addition to other factors that the Illinois Department finds appropriate, the Illinois Department may consider a health care provider's timely use or failure to use the protocol in considering the provider's failure to comply with this Code. (M) Notwithstanding any other provision of this Code, the Illinois Department, at its discretion, may exempt an entity licensed under the Nursing Home Care Act, the ID/DD Community Care Act, or the MC/DD Act from the provisions of subsections (A-15), (B), and (C) of this Section if the licensed entity is in receivership. (Source: P.A. 102-538, eff. 8-20-21.)
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(305 ILCS 5/12-4.25a) (from Ch. 23, par. 12-4.25a)
Sec. 12-4.25a.
Any vendor of physician services who shall be the
subject of a medical quality review by the Illinois Department shall have
the right to consult with another physician or physicians to assist in
understanding the procedures and interpretations of the Illinois
Department and to assist in interpreting, as an experienced or expert
consultant or witness, the quality of care, its relation to a prevailing
standard of care, and standards of documentation of the Illinois
Department. The consulting physician or physicians may be present at the
review meeting where the provider is present. The assistance offered by
the consulting physician or physicians shall respect the
confidentiality of recipient patient relations with the treating physician
in relation to consultation on treatment matters. Nothing in this
subsection shall be deemed to waive the requirements of the Medical Patient
Rights Act as it relates to patient privacy and confidentiality.
(Source: P.A. 87-399.)
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(305 ILCS 5/12-4.25b) (from Ch. 23, par. 12-4.25b)
Sec. 12-4.25b.
A vendor of physician services who is the subject of
medical quality review by the Illinois Department shall have the right to
record that portion of any Medical Quality Review Committee meeting or
hearing with the Illinois Department, at which the vendor is present and
participates. The recording shall be privileged and confidential
and shall not be disclosed, except however if the Illinois Department
initiates action to deny, suspend or terminate the vendor's participation
in the Medicaid program, the recording may be disclosed to an attorney or
physician consultant to prepare a defense.
(Source: P.A. 87-399.)
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(305 ILCS 5/12-4.25c) (from Ch. 23, par. 12-4.25c)
Sec. 12-4.25c.
Where a medical provider's medical practices are under
review by the Illinois Department and the provider is board certified in a
specialty by a nationally recognized specialty board and practicing in the
specialty, the Illinois Department should attempt to utilize a medical
practitioner with like qualifications to assist in reviewing the medical
practices of the provider under review in the areas of practice within the
specialty.
(Source: P.A. 87-399.)
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(305 ILCS 5/12-4.26) (from Ch. 23, par. 12-4.26)
Sec. 12-4.26.
Scope of Application.) The Illinois Department may terminate
or suspend a vendor pursuant to the authority and powers conferred in Section
12-4.25, only subsequent to the effective date of this amendatory Act.
However the authority and powers are expressly declared to be retroactive
to the extent that conduct and activities of vendors engaged in prior to
the effective date of this amendatory Act may be relied upon as the basis
for terminating or suspending eligibility to participate in the Medical
Assistance Program, where the vendor had actual or constructive knowledge
of the requirements which applied to his conduct or activities.
(Source: P.A. 80-2nd SS-2.)
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(305 ILCS 5/12-4.27) (from Ch. 23, par. 12-4.27)
Sec. 12-4.27.
Factual Determinations.) Factual determinations made by
the Department in administrative hearings initiated prior to the effective
date of this amendatory Act and which involve issues of fact relating to
activities which constitute grounds for termination pursuant to this amendatory
Act, shall be reviewed by the Director and may be used as grounds for approval
or denial of applications to participate, for termination of eligibility,
or for recovery of money, without conducting a new administrative proceeding.
(Source: P.A. 80-2nd SS-2.)
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(305 ILCS 5/12-4.28) (from Ch. 23, par. 12-4.28)
Sec. 12-4.28.
(Repealed).
(Source: P.A. 83-1362. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-4.29) (from Ch. 23, par. 12-4.29)
Sec. 12-4.29.
Youth employability and career development programs.
The
Illinois Department may establish and administer community-based programs
providing comprehensive, long-term intervention strategies to increase
future employability and career development among high risk youth, as
required by "An Act in relation to the provision of assistance to certain
persons, amending Acts named therein", certified December 2, 1987.
The Illinois Department may contract with private nonprofit
organizations or units of local government to administer and deliver
services pursuant to the above-named Act.
(Source: P.A. 85-1209.)
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(305 ILCS 5/12-4.30) (from Ch. 23, par. 12-4.30)
Sec. 12-4.30. Demonstration programs. Establish
demonstration programs, authorized by federal law and pursuant to State
regulations. Such demonstration programs may
include, but shall not be limited to: cashing out welfare benefits such as,
but not limited to, food stamps, energy assistance payments and medical
benefits; providing medical benefits through the purchase of health
insurance; and capping grant amounts at certain levels regardless of the
number of persons in the case. Such demonstration programs may be limited
to particular geographic areas.
(Source: P.A. 93-632, eff. 2-1-04.)
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(305 ILCS 5/12-4.31)
Sec. 12-4.31.
(Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 90-790, eff.
8-14-98.)
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(305 ILCS 5/12-4.32)
Sec. 12-4.32.
(Repealed).
(Source: P.A. 90-9, eff. 7-1-97. Repealed by P.A. 90-564, eff. 12-22-97.)
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(305 ILCS 5/12-4.33)
Sec. 12-4.33. Welfare reform research and accountability.
(a) The Illinois Department shall collect and report
upon all data in connection with federally funded or assisted welfare programs
as federal law may require, including, but not limited to, Section 411 of the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and its
implementing regulations and any amendments thereto as may from time to time be
enacted.
(b) In addition to and on the same schedule as the data collection required
by federal law and subsection (a), the Department shall collect and report on
further information with respect to the Temporary Assistance for Needy Families
("TANF") program, as follows:
(1) With respect to denials of applications for | ||
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(2) With respect to all terminations of benefits, all | ||
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(c) The Department shall collect all of the same data as set forth in
subsections (a) and (b), and report it on the same schedule, with respect to
all cash assistance benefits provided to families that are not funded from the
TANF program
federal block grant or are not otherwise required to be included in the data
collection and reporting in subsections (a) and (b).
(d) Whether or not reports under this Section must be submitted to the
federal government, they shall be considered public and they shall be promptly
made available to
the public at the end of
each fiscal year, free of charge upon request. The data underlying the reports
shall be made available to
academic institutions and public policy organizations
involved in the study of welfare issues or programs
and redacted to conform with applicable privacy
laws. The cost shall be no more than that incurred by the Department in
assembling and delivering the data.
(e) (Blank).
(f) (Blank).
(Source: P.A. 95-322, eff. 1-1-08.)
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(305 ILCS 5/12-4.34)
Sec. 12-4.34.
Services to noncitizens.
(a) Subject to specific appropriation for this purpose and notwithstanding
Sections 1-11 and 3-1 of this Code, the Department of Human Services is
authorized to provide services to legal immigrants, including but not limited
to naturalization and nutrition services and financial assistance. The nature
of these services, payment levels, and eligibility conditions shall be
determined by rule.
(b) The Illinois Department is authorized to lower the payment levels
established under this subsection or take such other actions during the
fiscal year as are necessary to ensure that payments under this subsection
do not exceed the amounts appropriated for this purpose. These changes
may be accomplished by emergency rule under Section 5-45 of the Illinois
Administrative Procedure Act, except that the limitation on the number of
emergency rules that may be adopted in a 24-month period shall not apply.
(Source: P.A. 91-24, eff. 7-1-99; 91-712, eff. 7-1-00; 92-10, eff.
6-11-01; 92-597, eff. 6-28-02.)
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(305 ILCS 5/12-4.35)
Sec. 12-4.35. Medical services for certain noncitizens.
(a) Notwithstanding
Section 1-11 of this Code or Section 20(a) of the Children's Health Insurance
Program Act, the Department of Healthcare and Family Services may provide medical services to
noncitizens who have not yet attained 19 years of age and who are not eligible
for medical assistance under Article V of this Code or under the Children's
Health Insurance Program created by the Children's Health Insurance Program Act
due to their not meeting the otherwise applicable provisions of Section 1-11
of this Code or Section 20(a) of the Children's Health Insurance Program Act.
The medical services available, standards for eligibility, and other conditions
of participation under this Section shall be established by rule by the
Department; however, any such rule shall be at least as restrictive as the
rules for medical assistance under Article V of this Code or the Children's
Health Insurance Program created by the Children's Health Insurance Program
Act.
(a-5) Notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical assistance in accordance with Article V of this Code to noncitizens over the age of 65 years of age who are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code, whose income is at or below 100% of the federal poverty level after deducting the costs of medical or other remedial care, and who would otherwise meet the eligibility requirements in Section 5-2 of this Code. The medical services available, standards for eligibility, and other conditions of participation under this Section shall be established by rule by the Department; however, any such rule shall be at least as restrictive as the rules for medical assistance under Article V of this Code. (a-6) By May 30, 2022, notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical services to noncitizens 55 years of age through 64 years of age who (i) are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code and (ii) have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined under applicable federal law and regulations. Persons eligible for medical services under Public Act 102-16 shall receive benefits identical to the benefits provided under the Health Benefits Service Package as that term is defined in subsection (m) of Section 5-1.1 of this Code. (a-7) By July 1, 2022, notwithstanding Section 1-11 of this Code, the Department of Healthcare and Family Services may provide medical services to noncitizens 42 years of age through 54 years of age who (i) are not eligible for medical assistance under Article V of this Code due to their not meeting the otherwise applicable provisions of Section 1-11 of this Code and (ii) have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined under applicable federal law and regulations. The medical services available, standards for eligibility, and other conditions of participation under this Section shall be established by rule by the Department; however, any such rule shall be at least as restrictive as the rules for medical assistance under Article V of this Code. In order to provide for the timely and expeditious implementation of this subsection, the Department may adopt rules necessary to establish and implement this subsection through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the General Assembly finds that the adoption of rules to implement this subsection is deemed necessary for the public interest, safety, and welfare. (a-10) Notwithstanding the provisions of Section 1-11, the Department shall cover immunosuppressive drugs and related services associated with post-kidney transplant management, excluding long-term care costs, for noncitizens who: (i) are not eligible for comprehensive medical benefits; (ii) meet the residency requirements of Section 5-3; and (iii) would meet the financial eligibility requirements of Section 5-2. (b) The Department is authorized to take any action that would not otherwise be prohibited by applicable law, including, without
limitation, cessation or limitation of enrollment, reduction of available medical services,
and changing standards for eligibility, that is deemed necessary by the
Department during a State fiscal year to assure that payments under this
Section do not exceed available funds.
(c) (Blank).
(d) (Blank).
(e) In order to provide for the expeditious and effective ongoing implementation of this Section, the Department may adopt rules through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the limitation on the number of emergency rules that may be adopted in a 24-month period shall not apply. For purposes of the Illinois Administrative Procedure Act, the General Assembly finds that the adoption of rules to implement this Section is deemed necessary for the public interest, safety, and welfare. This subsection (e) is inoperative on and after July 1, 2025. (Source: P.A. 102-16, eff. 6-17-21; 102-43, Article 25, Section 25-15, eff. 7-6-21; 102-43, Article 45, Section 45-5, eff. 7-6-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, eff. 6-16-23.)
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(305 ILCS 5/12-4.36)
Sec. 12-4.36. (Repealed).
(Source: P.A. 95-622, eff. 9-17-07. Repealed by P.A. 97-689, eff. 6-14-12.)
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(305 ILCS 5/12-4.37) Sec. 12-4.37. Children's Healthcare Partnership Pilot Program. (a) The Department of Healthcare and Family Services, in cooperation with the Department of Human Services, shall establish a Children's Healthcare Partnership Pilot Program in Sangamon County to fund the provision of various health care services by a single provider, or a group of providers that have entered into an agreement for that purpose, at a single location in the county. Services covered under the pilot program shall include, but need not be limited to, family practice, pediatric, nursing (including advanced practice registered nursing), psychiatric, dental, and vision services. The Departments shall fund the provision of all services provided under the pilot program using a rate structure that is cost-based. To be selected by the Departments as the provider of health care services under the pilot program, a provider or group of providers must serve a disproportionate share of low-income or indigent patients, including recipients of medical assistance under Article V of this Code. The Departments shall adopt rules as necessary to implement this Section. (b) Implementation of this Section is contingent on federal approval. The Department of Healthcare and Family Services shall take appropriate action by January 1, 2010 to seek federal approval. (c) This Section is inoperative if the provider of health care services under the pilot program receives designation as a Federally Qualified Health Center (FQHC) or FQHC Look-Alike.
(Source: P.A. 100-513, eff. 1-1-18.) |
(305 ILCS 5/12-4.38)
Sec. 12-4.38. Special FamilyCare provisions. The Department of Healthcare and Family Services may submit to the Comptroller, and the Comptroller is authorized to pay, on behalf of persons enrolled in the FamilyCare Program, claims for services rendered to an enrollee during the period beginning October 1, 2007, and ending on the effective date of any rules adopted to implement the provisions of this amendatory Act of the 96th General Assembly. The authorization for payment of claims applies only to bona fide claims for payment for services rendered. Any claim for payment which is authorized pursuant to the provisions of this amendatory Act of the 96th General Assembly must adhere to all other applicable rules, regulations, and requirements.
(Source: P.A. 96-20, eff. 6-30-09; 97-689, eff. 6-14-12.) |
(305 ILCS 5/12-4.39) Sec. 12-4.39. Dental clinic grant program. (a) Grant program. On and after July 1, 2012, and subject to funding availability, the Department of Healthcare and Family Services may administer a grant program. The purpose of this grant program shall be to build the public infrastructure for dental care and to make grants to local health departments, federally qualified health clinics (FQHCs), and rural health clinics (RHCs) for development of comprehensive dental clinics for dental care services. The primary purpose of these new dental clinics will be to increase dental access for low-income and Department of Healthcare and Family Services clients who have no dental arrangements with a dental provider in a project's service area. The dental clinic must be willing to accept out-of-area clients who need dental services, including emergency services for adults and Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-referral children. Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs) shall receive special priority for grants under this program. (b) Eligible applicants. The following entities are eligible to apply for grants: (1) Local health departments. (2) Federally Qualified Health Centers (FQHCs). (3) Rural health clinics (RHCs). (c) Use of grant moneys. Grant moneys must be used to support projects that develop dental services to meet the dental health care needs of Department of Healthcare and Family Services Dental Program clients.
Grant moneys must be used for operating expenses, including, but not limited to: insurance; dental supplies and equipment; dental support services; and renovation expenses.
Grant moneys may not be used to offset existing indebtedness, supplant existing funds, purchase real property, or pay for personnel service salaries for dental employees. (d) Application process. The Department shall establish procedures for applying for dental clinic grants.
(Source: P.A. 96-67, eff. 7-23-09; 96-1000, eff. 7-2-10; 97-689, eff. 6-14-12.) |
(305 ILCS 5/12-4.40) Sec. 12-4.40. Payment Recapture Audits. The Department of Healthcare and Family Services is authorized to contract with third-party entities to conduct Payment Recapture Audits to detect and recapture payments made in error or as a result of fraud or abuse. Payment Recapture Audits under this Section may be performed in conjunction with similar audits performed under federal authorization. A Payment Recapture Audit shall include the process of identifying improper payments paid to providers or other entities whereby accounting specialists and fraud examination specialists examine payment records and uncover such problems as duplicate payments, payments for services not rendered, overpayments, payments for unauthorized services, and fictitious vendors. This audit may include the use of professional and specialized auditors on a contingency basis, with compensation tied to the identification of misspent funds. The use of Payment Recapture Audits does not preclude the Office of the Inspector General or any other authorized agency employee from performing activities to identify and prevent improper payments.
(Source: P.A. 96-942, eff. 6-25-10; 97-333, eff. 8-12-11.) |
(305 ILCS 5/12-4.41) Sec. 12-4.41. Public Benefits Fraud Protection Task Force. (a) Purpose. The purpose of the Public Benefits Fraud Protection Task Force is to conduct a thorough review of the nature of public assistance fraud in the State of Illinois; to ascertain the feasibility of implementing a mechanism to determine the pervasiveness and frequency of public assistance fraud; to calculate the detriment of public assistance fraud to the financial status and socio-economic status of public aid recipients specifically and Illinois taxpayers generally; and to determine if more stringent penalties or compassionate procedures are necessary. (b) Definitions. As used in this Section: "Task Force" means the Public Benefits Fraud Protection Task Force. "Public assistance" or "public aid" includes, without limitation, Medicaid, TANF, the Illinois LINK Program, General Assistance, Transitional Assistance, the Supplemental Nutrition Assistance Program, and the Child Care Assistance Program. (c) The Public Benefits Fraud Protection Task Force. The Public Benefits Fraud Protection Task Force is created. The Task Force shall be composed of 17 members appointed as follows: (1) One member of the Illinois Senate appointed by | ||
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(2) One member of the Illinois Senate appointed by | ||
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(3) One member of the Illinois House of | ||
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(4) One member of the Illinois House of | ||
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(5) The following persons, or their designees: the | ||
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(6) The Director of the Illinois Department on Aging, | ||
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(7) The Executive Inspector General appointed by the | ||
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(8) The Inspector General of the Illinois Department | ||
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(9) A representative from the Office of the Attorney | ||
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(10) Three persons, who are not currently employed by | ||
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(11) The Attorney General, or his or her designee; (12) A representative of a union representing front | ||
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(13) A representative of a statewide business | ||
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(d) Compensation and qualifications. Members shall serve without compensation and shall be adults and residents of Illinois. (e) Appointments. Appointments shall be made 90 days from the effective date of this amendatory Act of the 96th General Assembly. (f) Hearings. The Task Force shall solicit comments from stakeholders and hold public hearings before filing any report required by this Section. At the public hearings, the Task Force shall allow interested persons to present their views and comments. The Task Force shall submit all reports required by this Section to the Governor and the General Assembly. In addition to the reports required by this Section, the Task Force may provide, at its discretion, interim reports and recommendations. The Department of Human Services shall provide administrative support to the Task Force. (g) Task Force duties. The Task Force shall gather information and make recommendations relating to at least the following topics in relation to public assistance fraud: (1) Reviews of provider billing of public aid claims. (2) Reviews of recipient utilization of public aid. (3) Protocols for investigating recipient public aid | ||
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(4) Protocols for investigating provider public aid | ||
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(5) Reporting of alleged fraud by private citizens | ||
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(6) Examination of current fraud prevention measures | ||
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(7) Coordination between relevant agencies in fraud | ||
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(8) Financial audit of the current costs borne by aid | ||
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(9) Examination of enhanced penalties for fraudulent | ||
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(10) Enhanced whistleblower protections. (11) Voluntary assistance from businesses and | ||
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(h) Task Force recommendations. Any of the findings, recommendations, public postings, and other relevant information regarding the Task Force shall be made available on the Department of Human Services' website. (i) Reporting requirements. The Task Force shall submit findings and recommendations to the Governor and the General Assembly by December 31, 2011, including any necessary implementing legislation, and recommendations for changes to policies, rules, or procedures that are not incorporated in the implementing legislation. (j) Dissolution of Task Force. The Task Force shall be dissolved 90 days after its report has been submitted to the Governor's Office and the General Assembly. (Source: P.A. 103-145, eff. 10-1-23.) |
(305 ILCS 5/12-4.42)
Sec. 12-4.42. Medicaid Revenue Maximization. (a) Purpose. The General Assembly finds that there is a need to make changes to the administration of services provided by State and local governments in order to maximize federal financial participation. (b) Definitions. As used in this Section: "Community Medicaid mental health services" means all mental health services outlined in Part 132 of Title 59 of the Illinois Administrative Code that are funded through DHS, eligible for federal financial participation, and provided by a community-based provider. "Community-based provider" means an entity enrolled as a provider pursuant to Sections 140.11 and 140.12 of Title 89 of the Illinois Administrative Code and certified to provide community Medicaid mental health services in accordance with Part 132 of Title 59 of the Illinois Administrative Code. "DCFS" means the Department of Children and Family Services. "Department" means the Illinois Department of Healthcare and Family Services. "Care facility for persons with a developmental disability" means an intermediate care facility for persons with an intellectual disability within the meaning of Title XIX of the Social Security Act, whether public or private and whether organized for profit or not-for-profit, but shall not include any facility operated by the State. "Care provider for persons with a developmental disability" means a person conducting, operating, or maintaining a care facility for persons with a developmental disability. For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court. "DHS" means the Illinois Department of Human Services. "Hospital" means an institution, place, building, or agency located in this State that is licensed as a general acute hospital by the Illinois Department of Public Health under the Hospital Licensing Act, whether public or private and whether organized for profit or not-for-profit. "Long term care facility" means (i) a skilled nursing or intermediate long term care facility, whether public or private and whether organized for profit or not-for-profit, that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act, including a county nursing home directed and maintained under Section 5-1005 of the Counties Code, and (ii) a part of a hospital in which skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act are provided; except that the term "long term care facility" does not include a facility operated solely as an intermediate care facility for the intellectually disabled within the meaning of Title XIX of the Social Security Act. "Long term care provider" means (i) a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility or (ii) a hospital provider that provides skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act. For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court. "State-operated facility for persons with a developmental disability" means an intermediate care facility for persons with an intellectual disability within the meaning of Title XIX of the Social Security Act operated by the State. (c) Administration and deposit of Revenues. The Department shall coordinate the implementation of changes required by Public Act 96-1405 amongst the various State and local government bodies that administer programs referred to in this Section. Revenues generated by program changes mandated by any provision in this Section, less reasonable administrative costs associated with the implementation of these program changes, which would otherwise be deposited into the General Revenue Fund shall be deposited into the Healthcare Provider Relief Fund. The Department shall issue a report to the General Assembly detailing the implementation progress of Public Act 96-1405 as a part of the Department's Medical Programs annual report for fiscal years 2010 and 2011. (d) Acceleration of payment vouchers. To the extent practicable and permissible under federal law, the Department shall create all vouchers for long term care facilities and facilities for persons with a developmental disability for dates of service in the month in which the enhanced federal medical assistance percentage (FMAP) originally set forth in the American Recovery and Reinvestment Act (ARRA) expires and for dates of service in the month prior to that month and shall, no later than the 15th of the month in which the enhanced FMAP expires, submit these vouchers to the Comptroller for payment. The Department of Human Services shall create the necessary documentation for State-operated facilities for persons with a developmental disability so that the necessary data for all dates of service before the expiration of the enhanced FMAP originally set forth in the ARRA can be adjudicated by the Department no later than the 15th of the month in which the enhanced FMAP expires. (e) Billing of DHS community Medicaid mental health services. No later than July 1, 2011, community Medicaid mental health services provided by a community-based provider must be billed directly to the Department. (f) DCFS Medicaid services. The Department shall work with DCFS to identify existing programs, pending qualifying services, that can be converted in an economically feasible manner to Medicaid in order to secure federal financial revenue. (g) (Blank). (h) Public health departments.
The Department shall identify unreimbursed costs for persons covered by Medicaid who are served by the Chicago Department of Public Health. The Department shall assist the Chicago Department of Public Health in determining total unreimbursed costs associated with the provision of healthcare services to Medicaid enrollees. The Department shall determine and draw the maximum allowable federal matching dollars associated with the cost of Chicago Department of Public Health services provided to Medicaid enrollees. (i) Acceleration of hospital-based payments.
The Department shall, by the 10th day of the month in which the enhanced FMAP originally set forth in the ARRA expires, create vouchers for all State fiscal year 2011 hospital payments exempt from the prompt payment requirements of the ARRA. The Department shall submit these vouchers to the Comptroller for payment.
(Source: P.A. 100-201, eff. 8-18-17; 101-209, eff. 8-5-19.)
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(305 ILCS 5/12-4.44) Sec. 12-4.44. Report on centralizing administrative functions. The Department of Healthcare and Family Services, with the cooperation of the Department of Human Services, shall provide a report to the General Assembly by January 1, 2012, regarding the feasibility and potential consequences of centralizing administrative functions, to the extent allowable under federal law, for applicants applying only for medical assistance. The report shall include, but need not be limited to, an analysis of centralizing administrative functions in a statewide or regional centers administered by either public or private entities, and an analysis of the impact of removing medical assistance only cases from the caseload assigned to employees in local Department of Human Services field offices that accept and process applications for benefits.
(Source: P.A. 97-172, eff. 7-22-11.) |
(305 ILCS 5/12-4.45) Sec. 12-4.45. Third party liability. (a) To the extent authorized under federal law, the Department of Healthcare and Family Services shall identify individuals receiving services under medical assistance programs funded or partially funded by the State who may be or may have been covered by a third party health insurer, the period of coverage for such individuals, and the nature of coverage. A company, as defined in Section 5.5 of the Illinois Insurance Code and Section 2 of the Comprehensive Health Insurance Plan Act, must provide the Department eligibility information in a federally recommended or mutually agreed-upon format that includes at a minimum: (1) The names, addresses, dates, and sex of primary | ||
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(2) The policy group numbers of the covered persons. (3) The names, dates of birth, and sex of covered | ||
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(4) The effective dates of coverage for each covered | ||
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(5) The generally defined covered services | ||
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(b) The Department may impose an administrative penalty on a company that does not comply with the request for information made under Section 5.5 of the Illinois Insurance Code and paragraph (3) of subsection (a) of Section 20 of the Covering ALL KIDS Health Insurance Act. The amount of the penalty shall not exceed $10,000 per day for each day of noncompliance that occurs after the 180th day after the date of the request. The first day of the 180-day period commences on the business day following the date of the correspondence requesting the information sent by the Department to the company. The amount shall be based on: (1) The seriousness of the violation, including the | ||
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(2) The economic harm caused by the violation. (3) The history of previous violations. (4) The amount necessary to deter a future violation. (5) Efforts to correct the violation. (6) Any other matter that justice may require. (c) The enforcement of the penalty may be stayed during the time the order is under administrative review if the company files an appeal. (d) The Attorney General may bring suit on behalf of the Department to collect the penalty. (e) Recoveries made by the Department in connection with the imposition of an administrative penalty as provided under this Section shall be deposited into the Public Aid Recoveries Trust Fund created under Section 12-9.
(Source: P.A. 98-130, eff. 8-2-13; 98-756, eff. 7-16-14.) |
(305 ILCS 5/12-4.46) Sec. 12-4.46. Change in legal guardianship; notification. Whenever there is a change in legal guardianship of a minor child who receives benefits under this Code, the appropriate State agency shall immediately inform the Department of Human Services of the change in legal guardianship to ensure such benefits are sent directly to the minor child's legal guardian. For purposes of this Section, "legal guardian" means a person appointed guardian, or given custody, of a minor by a circuit court of the State, but does not include a person appointed guardian, or given custody, of a minor under the Juvenile Court Act or the Juvenile Court Act of 1987.
(Source: P.A. 98-256, eff. 8-9-13; 98-756, eff. 7-16-14.) |
(305 ILCS 5/12-4.47) Sec. 12-4.47. Continued eligibility for developmental disability services for dependents of military service members. (a) As used in this Section: "Dependent" means a spouse, birth child, adopted child, or
stepchild of a military service member. "Legal resident" means a person who maintains Illinois as his
or her principal establishment, home of record, or permanent home and
to where, whenever absent due to military obligation, he or she intends
to return. "Military service" means service in the armed forces or armed
forces reserves of the United States, or membership in the Illinois National Guard. "Military service member" means a person who is currently in military service or who
has separated from military service in the previous 18 months through
either retirement or military separation. (b) A dependent, who is a legal resident of the State, having
previously been determined to be eligible for developmental disability
services provided by the Department of Human Services, including waiver services provided under the home and community based services programs authorized under Section 1915(c) of the Social Security Act, shall retain eligibility for those developmental disability services as long as he
or she remains a legal resident of the State, regardless of having left the State due to the military service member's military assignment
outside the State, and as long as he or she is otherwise eligible for such services. (c) The Department of Human Services shall permit a dependent who resides out-of-state to be placed on the waiting list for developmental disabilities services if the dependent left the State due to the military service member's military assignment outside the State, is otherwise eligible for those services, and furnishes the following: (1) a copy of the military service member's DD-214 or | ||
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(2) proof of the military service member's legal | ||
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(d) For dependents who received developmental disability services
and who left the State due to the military service member's military
assignment outside the State, upon the dependent's return to the State and when a request for services is made, the Department shall: (1) determine the dependent's eligibility for | ||
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(2) provide to the dependent notification of the | ||
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(3) provide the dependent an opportunity to contest | ||
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(4) resume services if the individual remains | ||
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(e) As a condition of continued eligibility for services under subsection (b) of this Section,
a dependent must inform the Department of his or her
current address and provide updates as requested by the Department. (f) No payment pursuant to this Section shall be made for developmental disability services authorized under the Illinois Title XIX State Plan and provided outside the State unless those services satisfy the conditions specified in 42 CFR 431.52. No payment pursuant to this Section shall be made for home and community based services provided outside the State of Illinois. (g) The Department shall request a waiver from the appropriate
federal agency if a waiver is necessary to implement the provisions of this
Section. (h) The Department may adopt rules necessary to implement the
provisions of this Section.
(Source: P.A. 98-1000, eff. 8-18-14; 99-78, eff. 7-20-15.) |
(305 ILCS 5/12-4.48) Sec. 12-4.48. Long-Term Services and Supports Disparities Workgroup. (a) The Department of Healthcare and Family Services shall establish a Long-Term Services and Supports Disparities Workgroup of the Medicaid Advisory Committee in accordance with the requirements of 42 CFR 431.12. (b) Members of the Workgroup shall be appointed by the Director of the Department of Healthcare and Family Services and may include representatives of the following agencies, organizations, or groups: (1) (Blank). (2) (Blank). (3) (Blank). (4) (Blank). (5) (Blank). (6) (Blank). (7) (Blank). (8) Managed Care Plans. (9) The for-profit urban nursing home or assisted | ||
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(10) The for-profit rural nursing home or assisted | ||
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(11) The not-for-profit nursing home or assisted | ||
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(12) The home care association or home care industry. (13) The adult day care association or adult day care | ||
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(14) An association representing workers who provide | ||
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(15) A representative of providers that serve the | ||
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(16) Case Management Organizations. (17) Three consumer representatives which may include | ||
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(b-5) In addition, one representative from each of the following may serve ex officio: the Governor's Office; the Department of Healthcare and Family Services; the Department of Human Services; the Department on Aging; the Department of Public Health; and the Department of Human Rights. (c) The Workgroup shall reflect diversity in race, ethnicity, and gender. (d) The Chair of the Workgroup shall be appointed by the Director of the Department of Healthcare and Family Services. (e) The Director of the Department of Healthcare and Family Services shall assign appropriate staff and resources to support the efforts of the Workgroup. The Workgroup shall meet as often as necessary but not less than 4 times per calendar year. (f) The Workgroup shall promote and facilitate communication, coordination, and collaboration among relevant State agencies and communities of color, limited English-speaking communities, and the private and public entities providing services to those communities. (g) The Workgroup shall do all of the following: (1) Document the number and types of Long-Term | ||
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(2) Document the number and racial profiles of | ||
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(3) Document the number and profiles of family or | ||
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(4) Compare data over multiple years to identify | ||
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(5) Identify any racial disparities in the provision | ||
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(6) Identify any disparities uniquely experienced in | ||
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(7) Assess whether the LTSS industry, including | ||
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(8) Consider whether to recommend that the State | ||
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(9) Identify and prioritize recommendations for | ||
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(10) Monitor the progress of the State in eliminating | ||
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(h) The Workgroup may conduct public hearings, inquiries, studies, and other forms of information gathering to identify how the actions of State government contribute to or reduce racial disparities in long-term care settings. (i) The Workgroup shall report its findings and recommendations to the Governor and the General Assembly with annual reports and shall include documentation of progress made to eliminate disparities in long-term care service settings.
(Source: P.A. 103-508, eff. 8-4-23.) |
(305 ILCS 5/12-4.49) Sec. 12-4.49. Breast cancer imaging and diagnostic equipment grant program. (a) On and after January 1, 2016 and subject to funding availability, the Department of Healthcare and Family Services shall administer a grant program the purpose of which shall be to build the public infrastructure for breast cancer imaging and diagnostic services across the State, in particular in rural, medically underserved areas and in areas with high breast cancer mortality. (b) In order to be eligible for the program, an applicant must be a: (1) disproportionate share hospital with high MIUR | ||
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(2) mammography facility in a rural area; (3) federally qualified health center; or (4) rural health clinic. (c) The grants may be used to purchase new equipment for breast imaging, image-guided biopsies, or other equipment to enhance the detection and diagnosis of breast cancer. (d) The primary purpose of these grants is to increase access for low-income and Department of Healthcare and Family Services clients to high quality breast cancer screening and diagnostics. Medically Underserved Areas (MUAs), areas with high breast cancer mortality rates, and Health Professional Shortage Areas (HPSAs) shall receive special priority for grants under this program. (e) The Department shall establish procedures for applying for grant funds under this Section.
(Source: P.A. 99-433, eff. 8-21-15.) |
(305 ILCS 5/12-4.50) Sec. 12-4.50. Healthy Local Food Incentives Program. (a) Legislative findings. Diet and other lifestyle choices contribute to more than half of all deaths in Illinois. Health risk factors include smoking, obesity, stress, nutrition, high blood pressure, and alcohol and drug use. Illinois residents should be encouraged to adopt diets and lifestyles that lead to wellness. The State can help provide that encouragement by funding wellness programs that enhance the health of Illinois residents. Healthy local food incentives encourage wellness among some of the most vulnerable residents of Illinois (those whose incomes are below the poverty line and who often have limited access to fresh, healthy, and affordable foods) by doubling the purchasing power of LINK cardholders at farmers markets across the State. The benefits of such a program include: an increase in population health, Medicaid health care cost savings, decreased incidence of preventable diseases, increased revenue for Illinois small farmers, and economic stimulus for the region. (b) Definitions. As used in this Section: "FINI eligible fruits and vegetables" means any variety of fresh, canned, dried, or frozen whole or cut fruits and vegetables without added sugars, fats, or oils, and salt (i.e. sodium), as defined by the Food Insecurity Nutrition Incentive Grant Program administered by the United States Department of Agriculture. "LINK card" means an electronic benefits transfer card issued by the Department of Human Services for the purpose of enabling a user of the card to obtain SNAP benefits or cash. "SNAP" means the federal Supplemental Nutrition Assistance Program. (c) The Department of Human Services shall establish a Healthy Local Food Incentives Program to double the purchasing power of Illinois residents with limited access to fresh fruits and vegetables. The Healthy Local Food Incentives Fund is created as a special fund in the State treasury for the purpose of implementing the Healthy Local Food Incentives Program. All moneys received pursuant to this Section shall be deposited into the Healthy Local Food Incentives Fund. (d) Subject to appropriation, the Department of Human Services shall make an annual grant of $500,000 from the Fund to a qualified Illinois non-profit organization or agency, which shall be distributed to participating Illinois farmers markets for the purpose of providing matching dollar incentives (up to a specified amount) for the dollar value of SNAP benefits spent on FINI eligible fruits and vegetables at participating Illinois farmers markets and direct producer-to-consumer venues. (e) The designated qualified non-profit organization or agency shall have a demonstrated track record of: (1) building a statewide network; (2) designing and implementing successful healthy | ||
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(3) implementing funds distribution and reporting | ||
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(4) providing training and technical assistance to | ||
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(5) conducting community outreach and data | ||
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(6) providing full accounting and administration of | ||
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(f) 100% of the moneys deposited into the Fund shall be distributed to participating Illinois farmers markets for healthy local food incentives. (g) Within 90 days after the end of a grant cycle, the designated qualified non-profit organization or agency shall submit a progress report to the Department of Human Services. The progress report shall include the following information: (1) the names and locations of Illinois farmers | ||
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(2) the dollar amount of funds awarded to each | ||
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(3) the dollar amount of SNAP benefits, and funds | ||
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(4) the number of SNAP transactions carried out | ||
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(5) the impact of the Program on increasing the | ||
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(h) No later than December 31, 2017, the Department of Human Services shall adopt rules to implement the provisions of this Section. (i) (Blank).
(Source: P.A. 99-928, eff. 1-20-17; 100-636, eff. 1-1-19.) |
(305 ILCS 5/12-4.51) Sec. 12-4.51. Workforce training and healthy families demonstration project. (a) Subject to the availability of funds provided for this purpose by the federal government, local philanthropic or charitable sources, or other private sources, there is created a 5-year demonstration project within the Department of Human Services to provide an intensive workforce training program for entry-level workers and a multi-generational healthy family initiative. No general revenue funds may be used to fund the demonstration project created under this Section. The demonstration project shall be implemented no later than 6 months after January 1, 2019 (the effective date of Public Act 100-806) and shall terminate 5 years after the initial date of implementation. The demonstration project shall be operated and maintained by a non-profit, community-based entity that shall provide the majority of the wages earned by participants enrolled in the workforce training program as well as support services to families, including new and expectant parents, enrolled in the multi-generational healthy family initiative. The total number of participants in the 5-year demonstration project at any one time shall not exceed 500. Participants enrolled in the workforce training program or the multi-generational healthy family initiative shall qualify to have whatever financial assistance they receive from their participation excluded from consideration for purposes of determining eligibility for or the amount of assistance under this Code as provided in subsection (d) of Section 1-7. The selected entity must immediately notify the Department of Human Services or the Department of Healthcare and Family Services whenever a participant enrolled in the workforce training program or the multi-generational healthy family initiative leaves the demonstration project and ceases to participate in any of the programs under the demonstration making the participant ineligible to receive an exemption as provided in subsection (d) of Section 1-7. (b) The entity selected to operate and maintain the demonstration project shall be a non-profit, community-based entity in good standing with the State that is located in a county with a population of less than 3,000,000. The selected entity must comply with all applicable State and federal requirements and must develop and implement a research component to determine the effectiveness of the demonstration project in promoting and instilling self-sufficiency through its intensive workforce training program and multi-generational healthy family initiative. The State shall not fund the research component outlined in the Section or any program under the demonstration project. (c) Beginning one year after the initial implementation date of the demonstration project, and each year thereafter for the duration of the demonstration, the selected entity shall submit a report to the Department of Human Services, the Department of Healthcare and Family Services, and the General Assembly that details the progress and effectiveness of the demonstration project and the demonstration's impact on instilling the value of self-sufficiency in participants. The 4th annual report shall also provide policy recommendations on best practices for and continued research on facilitating bridges to self-sufficiency. The 4th annual report may also include a recommendation on making the demonstration project permanent upon completion of the demonstration project period. The reports to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 100-806, eff. 1-1-19; 101-81, eff. 7-12-19.) |
(305 ILCS 5/12-4.52) Sec. 12-4.52. Prescriber education. (a) The Department of Healthcare and Family Services shall develop, in collaboration with a public university that has a Doctor of Pharmacy Professional Program and is located in a county with a population of more than 3,000,000, a program designed to provide
prescribing physicians under the medical assistance program with an evidence-based, non-commercial source of the latest
objective information about pharmaceuticals. Information shall be
presented to prescribing physicians by specially trained pharmacists, nurses, or
other health professionals to assist prescribing physicians in making
appropriate therapeutic recommendations. (b) The prescriber education program shall consist of 2 components: a web-based curriculum and an academic educator outreach. The program shall contract with clinical pharmacists to provide scheduled visits with prescribing physicians to update them on the latest research concerning medication usage and new updates on disease states in an unbiased manner. (c) Education provided under the prescriber education program shall include, but not be limited to, disease-based educational modules on the treatment of chronic non-cancer pain, diabetes, hypertension, hyperlipidemia, respiratory syncytial virus, and nicotine dependence. New modules may be created periodically as needed and existing module content shall be reviewed and updated on an annual or as-needed basis. Educational modules provided under the program shall provide prescribing physicians with continuing medical education credit. (d) Additional resources provided under the prescriber education program shall include, but not be limited to, the following: (1) a drug information response center available to | ||
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(2) information on drug utilization trends within | ||
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(Source: P.A. 101-278, eff. 1-1-20.) |
(305 ILCS 5/12-4.53) Sec. 12-4.53. Prospective Payment System (PPS) rates. Effective January 1, 2021, and subsequent years, based on specific appropriation, the Prospective Payment System (PPS) rates for FQHCs shall be increased based on the cost principles found at 45 Code of Federal Regulations Part 75 or its successor. Such rates shall be increased by using any of the following methods: reducing the current minimum productivity and efficiency standards no lower than 3500 encounters per FTE physician; increasing the statewide median cost cap from 105% to 120%, a one-time re-basing of rates utilizing 2018 FQHC cost reports, or another alternative payment method acceptable to the Centers for Medicare and Medicaid Services and the FQHCs, including an across the board percentage increase to existing rates.
(Source: P.A. 101-636, eff. 6-10-20; 101-655, eff. 3-12-21.) |
(305 ILCS 5/12-4.54) Sec. 12-4.54. SNAP, WIC; diapers, menstrual hygiene products. If the United States Department of Agriculture's Food and Nutrition Service creates and makes available to the states a waiver permitting recipients of benefits provided under the Supplemental Nutrition Assistance Program or the Special Supplemental Nutrition Program for Women, Infants, and Children to use their benefits to purchase diapers or menstrual hygiene products such as tampons, sanitary napkins, and feminine wipes, then the Department of Human Services shall apply for the waiver. If the United States Department of Agriculture approves the Department of Human Services' waiver application, then the Department of Human Services shall adopt rules and make other changes as necessary to implement the approved waiver.
(Source: P.A. 102-248, eff. 1-1-22; 102-813, eff. 5-13-22.) |
(305 ILCS 5/12-4.55)
Sec. 12-4.55. Community-based long-term services; application for federal funding. The Department of Healthcare and Family Services shall apply for all available federal funding to promote community inclusion and integration for persons with disabilities, regardless of age, and older adults so that those persons have the option to transition out of institutions and receive long-term care services and supports in the settings of their choice.
(Source: P.A. 102-536, eff. 8-20-21; 102-813, eff. 5-13-22.)
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(305 ILCS 5/12-4.56) Sec. 12-4.56. Managed Primary Care Demonstration Project. The Department shall establish and implement a Managed Primary Care Demonstration Project to provide primary care services that are focused on preventive rather than curative care to persons who reside in underserved communities that lack accessible health and medical services. The demonstration project shall operate for a 5-year period and provide supplemental services to medical assistance recipients. The Department shall contract with a health care organization through a competitive process that is capable of providing patient-centered, prevention-focused services, that may include, but are not limited to, the following: (1) Patient navigators to manage patient care. (2) Patient-tailored preventive health care plans. (3) Administrative personal health care consultants | ||
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(4) Clinical personal health care consultants for | ||
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(5) A patient portal. (6) An online virtual health hub that provides | ||
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(7) Community health and human services centers to | ||
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(8) Mobile preventive health stations and kiosks to | ||
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(9) Call centers to interact with medical homes and | ||
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A request for proposals for the demonstration project shall be issued by December 31, 2022.
(Source: P.A. 102-699, eff. 4-19-22.) |
(305 ILCS 5/12-4.57) Sec. 12-4.57. Prospective Payment System rates; increase for federally qualified health centers. Beginning January 1, 2024, subject to federal approval, the Department of Healthcare and Family Services shall increase the Prospective Payment System rates for federally qualified health centers to a level calculated to spend an additional $50,000,000 in the first year of application using an alternative payment method acceptable to the Centers for Medicare and Medicaid Services and a trade association representing a majority of federally qualified health centers operating in Illinois, including a rate increase that is an equal percentage increase to the rates paid to each federally qualified health center.(Source: P.A. 103-102, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/12-4.58) Sec. 12-4.58. Stolen SNAP benefits via card skimming; data collection and reports. (a) As the State administrator of benefits provided under the federally funded Supplemental Nutrition Assistance Program (SNAP), the Department of Human Services shall track and collect data on the scope and frequency of SNAP benefits fraud in this State where a SNAP recipient's benefits are stolen from the recipient's electronic benefits transfer card by means of card skimming, card cloning, or some other similar fraudulent method. The Department shall specifically keep a record of every report made to the Department by a SNAP recipient alleging the theft of benefits due to no fault of the recipient, the benefit amount stolen, and, if practicable, how those stolen benefits were used and the location of those thefts. (b) The Department shall report its findings to the General Assembly on an annual basis beginning on January 1, 2024. The Department shall file an annual report no later than the 60th day of the following year following each reporting period. A SNAP recipient's personally identifiable information shall be excluded from the reports consistent with State and federal privacy protections. Each annual report shall also be posted on the Department's official website. (c) If the Department determines that a SNAP recipient has made a substantiated report of stolen benefits due to card skimming, card cloning, or some other similar fraudulent method, the Department shall refer the matter to the State's Attorney who has jurisdiction over the alleged theft or fraud and shall provide any assistance to that State's Attorney in the prosecution of the alleged theft or fraud.(Source: P.A. 103-297, eff. 1-1-24; 103-605, eff. 7-1-24.) |
(305 ILCS 5/12-4.59) (This Section may contain text from a Public Act with a delayed effective date) Sec. 12-4.59. Informational guide on Medicaid 5-year look-back period. (a) Informational guide. On and after July 1, 2025, the Department of Healthcare and Family Services shall develop, post, and maintain on its official website a comprehensive informational guide that explains the Medicaid 5-year look-back period as it applies to eligibility for long-term care coverage under the medical assistance program established under Article V of this Code. The contents of the informational guide must include the following: (1) Overview of the Medicaid 5-year look-back period: | ||
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(2) Eligibility criteria affected by the Medicaid | ||
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(3) Calculation of the Medicaid 5-year look-back | ||
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(4) Examples and scenarios: Real-life examples and | ||
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(5) Transfers or gifts during the Medicaid 5-year | ||
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(6) Exceptions and exemptions: Information on | ||
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(7) Documentation requirements: Guidance on the | ||
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(8) Planning for eligibility: Tips and considerations | ||
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(9) Appeals and dispute resolution: Information on | ||
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(10) Contact information and resources: Clear and | ||
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(11) Frequently asked questions: A "Frequently Asked | ||
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(b) Accessibility of the guide. To ensure user-friendly navigation and visibility, the Department of Healthcare and Family Services shall post on its official website detailed information on how users can easily access the comprehensive guide on the website and a hyperlink that directs users to the comprehensive guide.(Source: P.A. 103-997, eff. 1-1-25.) |
(305 ILCS 5/12-4.101)
Sec. 12-4.101.
(Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-4.102)
Sec. 12-4.102.
(Repealed).
(Source: P.A. 88-412. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-4.103)
Sec. 12-4.103.
Individual Development Accounts.
Subject to funding availability, the Illinois Department shall
establish a program that allows eligible low-income
individuals to open and maintain Individual Development Accounts for the
purpose of enabling the individual to accumulate funds for a qualified purpose.
A qualified purpose for establishing an Individual Development Account shall
be one or more of the following:
(1) to pay for postsecondary education expenses if the expenses are paid
directly to an eligible educational institution;
(2) to acquire a principal residence if the individual is buying a home for
the first time and if the funds are paid directly to the person to whom the
amounts required for the purchase are due; or
(3) to finance business capitalization expenses if the funds are paid
directly into a business capitalization account at a federally insured
financial institution and are restricted to use solely for qualified business
capitalization expenses.
An individual may make contributions to his or her
Individual Development Account only from earned income as
defined in Section 911(d)(2) of the Internal Revenue Code of 1986.
An Individual Development Account program shall be established in
accordance with subsection (h) of Section 404 of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996. State funds made available
for this program and federal funds, to the extent they may be used for this
purpose, shall be used (i) to match, dollar for dollar, contributions made by
individuals participating in an Individual Development Account program approved
by the Illinois Department, (ii) to fund or supplement other funds available
for the costs of the administration of an Individual Development Account
program by a not-for-profit organization, and (iii) for a grant or grants to
not-for-profit organizations to provide technical assistance and training to
other not-for-profit organizations in the State that wish to establish an
Individual Development Account program consistent with this Section. No
Individual Development Account program shall qualify for State funds under this
Section unless the administering not-for-profit organization verifies that it
has secured at least a dollar for dollar match from
other sources for contributions made by participating individuals.
The Illinois Department shall by rule establish qualifications for a
not-for-profit organization to administer an Individual Development Account
program.
The Illinois Department shall establish eligibility criteria for individuals
seeking to participate in an Individual Development Account program. The
Illinois Department shall promulgate rules regarding the administration of
Individual Development Account programs by approved not-for-profit
organizations administering the programs.
Notwithstanding any other provision of State law, funds in an Individual
Development Account, including accrued interest and matching deposits, shall be
disregarded for the purpose of determining the eligibility and benefit levels
under this Code of the individual establishing the Individual Development
Account with respect to any period during which such individual maintains or
makes contributions into such an account.
Nothing in this Section shall prohibit a not-for-profit organization which does
not
receive State matching funds from administering an approved Individual
Development Account under this Section.
(Source: P.A. 90-783, eff. 8-14-98.)
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(305 ILCS 5/12-4.103a) Sec. 12-4.103a. Assets for Independence Program. (a) Program established. Subject to available funding and receipt of a federal Assets for Independence grant award, the Department of Human Services shall establish and administer an Assets for Independence Program (Program). The Program shall be established in accordance with the terms of the Assets for Independence Act (AFIA) as now and hereafter amended (Title IV Community Opportunities, Accountability, and Training and Educational Services Act as amended, Public Law 105-285, 42 U.S.C. 604 note). (b) Assets for Independence Fund. The Assets for Independence Fund is established. The Fund shall be held by the Secretary or his or her designee as ex-officio custodian thereof separate and apart from all other State funds. The Assets for Independence Fund is authorized to receive grants under AFIA, State moneys appropriated for the Program, and moneys from voluntary donations from individuals, foundations, corporations, and other sources. Moneys in the Assets for Independence Fund shall not be commingled with other State funds, but they shall be deposited as required by law and maintained in a separate account on the books of a savings and loan association, bank, or other qualified financial institution. All interest earnings on amounts within the Assets for Independence Fund shall accrue to the Assets for Independence Fund and shall be used in accordance with the terms of the AFIA. Administrative expenses related to the Program, including the provision of financial education to Program participants, shall be paid from the Assets for Independence Fund in accordance with the terms of AFIA Section 707(c)(3). (c) Program purpose. The purpose of the Program is to allow eligible low-income Illinois citizens, subject to the availability of State and federal funds and authorization from the Department, to open and maintain an Individual Development Account (IDA) at a federally insured financial institution. Deposits into an IDA that are used for subsequent qualified purchases shall be matched dollar-for-dollar by moneys from the Assets for Independence Fund. Not more than $2,000 of moneys from the Assets for Independence Fund shall be provided to any one individual. Not more than $4,000 of moneys from the Assets for Independence Fund shall be provided to any one household. Assets for Independence Fund moneys not being used to administer the Program shall be used only for qualified purchases, shall be distributed only directly to the vendor of a qualified purchase, and shall require the authorization by signature of the Department's chief financial officer. (d) Contributions to IDA and use of moneys. An individual may make contributions to his or her IDA only from earned income as defined in Section 911(d)(2) of the Internal Revenue Code of 1986. The moneys deposited into an IDA shall not be commingled with any Assets for Independence Fund moneys. An IDA holder shall have a 36-month period, beginning on the date the Department authorizes the holder to open the IDA, within which to make a qualified purchase. If a qualified purchase is not made within that 36-month period, Assets for Independence Fund moneys earmarked for that individual shall be released, and the Department shall authorize another eligible person to open an IDA. Under no circumstances, and at no time, shall an IDA holder lose the ability to withdraw moneys from his or her IDA. (e) Qualified purchases. A qualified asset purchase using moneys from an IDA shall be defined in accordance with AFIA Section 404(8) and shall be one or more of the following: (1) Payment of post-secondary education expenses, if | ||
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(2) Acquisition of a principal residence, if the | ||
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(3) Financing of business capitalization expenses, if | ||
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(f) Program eligibility. Program eligibility shall be established by the Department in accordance with AFIA Section 408. Persons eligible to open an IDA and to receive Assets for Independence Fund moneys are Illinois citizens currently residing in Illinois who are (i) able to demonstrate that they are currently eligible for assistance under the State's Temporary Assistance for Needy Families program or (ii) able to demonstrate that the adjusted gross income of their household in the calendar year preceding the determination of eligibility was equal to or less than 200% of the poverty line, as determined by the Federal Office of Management and Budget. An individual must further demonstrate that the net worth of his or her household, as of the end of the calendar year preceding the determination of eligibility, does not exceed $10,000, as determined by AFIA Section 408(2)(B). Notwithstanding any other provision of State law, moneys in an Individual Development Account, including accrued interest and matching deposits, shall be disregarded for the purpose of determining the eligibility and benefit levels under this Code in the case of the individual establishing the IDA with respect to any period during which the individual maintains or makes contributions into the IDA. The Department shall approve an individual to open an IDA at a federally insured financial institution upon determining, based on the individual's application, that all eligibility criteria are met and subject to the availability of $2,000 in Assets for Independence Fund moneys.
(Source: P.A. 94-1043, eff. 7-24-06.) |
(305 ILCS 5/12-4.104)
Sec. 12-4.104.
Family and Community Development Grant Program.
(a) Subject to funding availability, a family and community development
grant
program shall be administered by the Department
of
Human Services. The program shall be designed to make services
available to families who are at risk of long-term economic
dependency and to work with communities to provide economic opportunities. The
purpose of the program is to fund, evaluate, and provide
recommendations on not less than 8 nor more than 10 projects to
move 100 families at risk of
long-term economic dependency to self-sufficiency through the family and
community development program.
(b) As used in this Section only:
"Applicant" means a public or private organization that makes application
for a grant through the request for proposals process.
"Council" means the Social Services Advisory Council.
"Department" means the Department of Human Services.
"Grant" means an award to fund a project approved by the
Department with the advice of the Council.
"Grantee" means the recipient of a grant approved by the Department.
(c) The Social Services Advisory Council as established within
the Department of Human Services shall,
with
respect to the family and community development
grants
administered by the Department,
involve a representative of the Human Resource
Investment Council in considering proposed projects and monitoring approved
projects.
(d) The Council shall:
(1) Identify the factors and conditions that place | ||
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(2) Identify the factors and conditions that place | ||
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(3) Report those findings to the Secretary of Human | ||
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(4) Recommend grants to public or private | ||
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(5) In cooperation with the Illinois Community Action | ||
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(6) Seek the support of an Illinois accredited | ||
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(7) Seek additional support for the funding of family | ||
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(8) Make recommendations to the Governor, the General | ||
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(9) Evaluate and make recommendations regarding the | ||
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(e) In cooperation with the Illinois Community Action Association,
the grantees shall identify families that
receive TANF (formerly AFDC)
payments that may place families at
risk of long-term economic
dependency.
(f) The Department shall adopt rules for the operation of this program.
(Source: P.A. 90-783, eff. 8-14-98.)
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(305 ILCS 5/12-4.105) Sec. 12-4.105. Human poison control center; payment program. Subject to funding availability resulting from transfers made from the Hospital Provider Fund to the Healthcare Provider Relief Fund as authorized under this Code, for State fiscal year 2017 and State fiscal year 2018, and for each State fiscal year thereafter in which the assessment under Section 5A-2 is imposed, the Department of Healthcare and Family Services shall pay to the human poison control center designated under the Poison Control System Act an amount of not less than $3,000,000 for each of State fiscal years 2017 through 2020, and for State fiscal years 2021 through 2023 an amount of not less than $3,750,000 and for State fiscal years 2024 through 2026 an amount of not less than $4,000,000 and for the period July 1, 2026 through December 31, 2026 an amount
of not less than $2,000,000, if the human poison control center is in operation.
(Source: P.A. 102-886, eff. 5-17-22; 103-102, eff. 6-16-23.) |
(305 ILCS 5/12-4.201)
Sec. 12-4.201. Data warehouse concerning medical and related
services. (a) The Department of Healthcare and Family Services may purchase services and
materials associated with the costs of developing and implementing a data
warehouse comprised of management and decision making information in
regard to the liability associated with, and utilization of, medical and
related services, out of moneys available for that purpose. (b) The Department of Healthcare and Family Services shall perform all necessary administrative functions to expand its linearly-scalable data warehouse to encompass other healthcare data sources at both the Department of Human Services and the Department of Public Health. The Department of Healthcare and Family Services shall leverage the inherent capabilities of the data warehouse to accomplish this expansion with marginal additional technical administration. The purpose of
this expansion is to allow for programmatic review and analysis including the interrelatedness among the various healthcare programs in order to ascertain effectiveness toward, and ultimate impact on, clients. Beginning
July 1, 2005, the Department of Healthcare and Family Services (formerly Department of Public Aid) shall supply quarterly reports to the Commission on Government Forecasting and Accountability detailing progress toward this mandate.
(c) The Department of Healthcare and Family Services (HFS), the Illinois Department of Public Health, the Illinois Department of Human Services, and the Division of Specialized Care for Children, University of Illinois at Chicago, with necessary support from the Department of Central Management Services, shall integrate into the medical data warehouse individual record level data owned by one of these agencies that pertains to maternal and child health, including the following data sets:
(1) Vital Records as they relate to births, birth | ||
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(2) Adverse Pregnancy Outcomes Reporting System | ||
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(3) Genetics/Newborn Screenings/SIDS. (4) Cornerstone (WIC, FCM, Teen Parents, | ||
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(5) HFS medical claims data. (6) I-CARE. (7) Children with Special Healthcare Needs Data. By September 1, 2009, the departments of Healthcare and Family Services, Public Health, and Human Services and the Division of Specialized Care for Children shall jointly prepare a work plan for fully integrating these data sets into the medical data warehouse. The work plan shall provide an overall project design, including defining a mutually acceptable transfer format for each discrete data set, the data update frequency, and a single method of data transfer for each data set. By October 1, 2009, the Department of Public Health shall grant to the Department of Healthcare and Family Services complete access to all vital records data. The Department of Public Health shall prepare a report detailing that this task has been accomplished and submit this report to the Commission on Government Forecasting and Accountability by October 15, 2009. By March 1, 2010, the data sets shall be completely loaded into the medical data warehouse. By July 1, 2010, data from the various sources shall be processed so as to be compatible with other data in the medical data warehouse and available for analysis in an integrated manner. With the cooperation of the other agencies, HFS shall submit status reports on the progress of these efforts to the Governor and the General Assembly no later than October 1, 2009 and April 1, 2010, with a final report due no later than November 1, 2010. On an ongoing basis, the 4 agencies shall review the feasibility of adding data from additional sources to the warehouse. Such review may take into account the cost effectiveness of adding the data, the utility of adding data that is not available as identifiable individual record level data, the requirements related to adding data owned by another entity or not available in electronic form, whether sharing of the data is otherwise prohibited by law and the resources required and available for effecting the addition. The departments shall use analysis of the data in the medical data warehouse to improve maternal and child health outcomes, and in particular improve birth outcomes, and to reduce racial health disparities in this area. All access and use of the data shall be in compliance with all applicable federal and State laws, regulations, and mandates. Notwithstanding anything in this Section, data incorporated into the data warehouse shall remain subject to the same provisions of law regarding confidentiality and use restrictions as they are subject to in the control of the contributing agency. The Department of Healthcare and Family Services shall develop measures to ensure that the interplay of the several data sets contributed to the data warehouse does not lead to the use or release of data from the data warehouse that would not otherwise be subject to use or release under State or federal law.(Source: P.A. 95-331, eff. 8-21-07; 96-799, eff. 10-28-09; 96-1000, eff. 7-2-10.)
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(305 ILCS 5/12-4.202)
Sec. 12-4.202. (Repealed).
(P.A. 94-267, eff. 7-19-05. Repealed internally, eff. 1-1-06.)
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(305 ILCS 5/12-5) (from Ch. 23, par. 12-5)
Sec. 12-5. Appropriations; uses; federal grants; report to
General Assembly. From the sums appropriated by the General Assembly,
the Illinois Department shall order for payment by warrant from the State
Treasury grants for public aid under Articles III, IV, and V,
including
grants for funeral and burial expenses, and all costs of administration of
the Illinois Department and the County Departments relating thereto. Moneys
appropriated to the Illinois Department for public aid under Article VI may
be used, with the consent of the Governor, to co-operate
with federal, State, and local agencies in the development of work
projects designed to provide suitable employment for persons receiving
public aid under Article VI. The Illinois Department, with the consent
of the Governor, may be the agent of the State for the receipt and
disbursement of federal funds or commodities for public aid purposes
under Article VI and for related purposes in which the
co-operation of the Illinois Department is sought by the federal
government, and, in connection therewith, may make necessary
expenditures from moneys appropriated for public aid under any Article
of this Code and for administration. The Illinois Department may make necessary expenditures from monies
appropriated to it for operations, administration, and grants, including
payment to the Health Insurance Reserve Fund for group insurance costs at
the rate certified by the Department of Central Management Services.
All grants received by the Illinois Department for programs funded by the
Federal Social Services Block Grant shall be deposited in the Social Services
Block Grant Fund. All funds received into the Social Services Block Grant Fund
as reimbursement for expenditures from the General Revenue Fund shall be
transferred to the General Revenue Fund. All funds received into the Social
Services Block Grant fund for reimbursement for expenditure out of the Local
Initiative Fund shall be transferred into the Local Initiative Fund. Any other
federal funds received into the Social Services Block Grant Fund shall be
transferred to the DHS Special Purposes Trust Fund. All federal funds received by
the Illinois Department as reimbursement for Employment and Training Programs
for expenditures made by the Illinois Department from grants, gifts, or
legacies as provided in Section 12-4.18 or made by an entity other than the
Illinois Department and all federal funds received from the Emergency Contingency Fund for State Temporary Assistance for Needy Families Programs established by the American Recovery and Reinvestment Act of 2009 shall be deposited into the Employment and Training Fund.
During each State fiscal year, an amount not exceeding a total of $68,800,000 of the federal funds received by the
Illinois Department under the provisions of Title IV-A of the federal Social Security Act shall be deposited
into the DCFS Children's Services
Fund.
All federal funds, except those covered by the foregoing 3
paragraphs, received as reimbursement for expenditures from the General Revenue
Fund shall be deposited in the General Revenue Fund for administrative and
distributive expenditures properly chargeable by federal law or regulation to
aid programs established under Articles III through XII and Titles IV, XVI, XIX
and XX of the Federal Social Security Act. Any other federal funds received by
the Illinois Department under Sections 12-4.6, 12-4.18 and
12-4.19 that are required by Section 12-10 of this Code to be paid into the
DHS Special Purposes Trust Fund shall be deposited into the DHS Special Purposes Trust
Fund. Any other federal funds received by the Illinois Department pursuant to
the Child Support Enforcement Program established by Title IV-D of the Social
Security Act shall be deposited in the Child Support Enforcement Trust Fund
as required under Section 12-10.2 or in the Child Support Administrative Fund as required under Section 12-10.2a of this Code. Any other federal funds received by the Illinois Department for
expenditures made under Title XIX of the Social Security Act and Articles
V and VI of this Code that are required by Section 15-2 of this Code
to be paid into the County Provider Trust Fund shall be deposited
into the County Provider Trust Fund. Any other federal funds received
by the Illinois Department for hospital
inpatient, hospital ambulatory care, and disproportionate share hospital
expenditures made under Title XIX of the Social Security Act and Article V of
this Code that are required by Section 5A-8 of this Code to be paid into the
Hospital Provider Fund shall be deposited into the Hospital Provider Fund. Any
other federal funds received by the Illinois Department for medical
assistance program expenditures made under Title XIX of the Social Security
Act and Article V of this Code that are required by Section 5B-8 of this
Code to be paid into the Long-Term Care Provider Fund shall be deposited
into the Long-Term Care Provider Fund. Any other federal funds received by
the Illinois Department for medical assistance program expenditures made
under Title XIX of the Social Security Act and Article V of this Code that
are required by Section 5C-7 of this Code to be paid into the
Care Provider Fund for Persons with a Developmental Disability shall be deposited into the
Care Provider Fund for Persons with a Developmental Disability. Any other federal funds received
by the Illinois Department for trauma center
adjustment payments that are required by Section 5-5.03 of this Code and made
under Title XIX of the Social Security Act and Article V of this Code shall be
deposited into the Trauma Center Fund. Any other federal funds received by
the Illinois Department as reimbursement for expenses for early intervention
services paid from the Early Intervention Services Revolving Fund shall be
deposited into that Fund.
The Illinois Department shall report to the General Assembly at the
end of each fiscal quarter the amount of all funds received and paid into
the Social Services Block Grant Fund and the Local Initiative Fund and the
expenditures and transfers of such funds for services, programs and other
purposes authorized by law. Such report shall be filed with the Speaker,
Minority Leader and Clerk of the House, with the President, Minority Leader
and Secretary of the Senate, with the Chairmen of the House and Senate
Appropriations Committees, the House Human Resources Committee and the
Senate Public Health, Welfare and Corrections Committee, or the successor
standing Committees of each as provided by the rules of the House and
Senate, respectively, with the Commission on Government Forecasting and Accountability and with the State
Government Report Distribution Center for the General Assembly as is
required under paragraph (t) of Section 7 of the State Library Act
shall be deemed sufficient to comply with this Section.
(Source: P.A. 100-587, eff. 6-4-18; 100-863, eff. 8-14-18; 100-1148, eff. 12-10-18; 101-275, eff. 8-9-19.) |
(305 ILCS 5/12-6) (from Ch. 23, par. 12-6)
Sec. 12-6.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
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(305 ILCS 5/12-8) (from Ch. 23, par. 12-8)
Sec. 12-8. Public Assistance Emergency Revolving Fund - Uses. The
Public Assistance Emergency Revolving Fund, established by Act approved
July 8, 1955 shall be held by the Illinois Department and shall be used
for the following purposes:
1. To provide immediate financial aid to applicants | ||
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2. To provide emergency aid to recipients under said | ||
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3. To provide emergency aid for transportation, meals | ||
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4. To provide emergency transportation expense | ||
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5. To assist public aid applicants in obtaining | ||
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6. To provide immediate payments to current or former | ||
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7. To provide payments to individuals or providers of | ||
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8. To provide immediate payment of fees, as follows: (A) To sheriffs and other public officials | ||
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(B) To county clerks, recorders of deeds, and | ||
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(C) To State and local officials in connection | ||
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(D) To the State Registrar of Vital Records, | ||
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Disbursements from the Public Assistance Emergency Revolving Fund
shall be made by the Illinois Department.
Expenditures from the Public Assistance Emergency Revolving Fund
shall be for purposes which are properly chargeable to appropriations
made to the Illinois Department, or, in the case of payments under subparagraphs 6 and 8, to the Child Support Enforcement Trust Fund or the Child Support Administrative Fund, except that no expenditure, other than payment of the fees provided for under subparagraph 8 of this Section,
shall be made for purposes which are properly chargeable to appropriations
for the following objects: personal services; extra help; state contributions
to retirement system; state contributions to Social Security; state
contributions for employee group insurance; contractual services; travel;
commodities; printing; equipment; electronic data processing; operation of
auto equipment; telecommunications services; library books; and refunds.
The Illinois Department shall reimburse the Public Assistance Emergency
Revolving Fund by warrants drawn by the State Comptroller on the
appropriation or appropriations which are so chargeable, or, in the case of
payments under subparagraphs 6 and 8, by warrants drawn on the Child Support
Enforcement Trust Fund or the Child Support Administrative Fund, payable to the Revolving Fund.
(Source: P.A. 103-102, eff. 1-1-24.)
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(305 ILCS 5/12-8.1)
Sec. 12-8.1.
State Disbursement Unit Revolving Fund.
(a) There is created a revolving fund to be known as the State Disbursement
Unit Revolving Fund, to be held by the Director of the Illinois Department,
outside the State treasury,
for the following purposes:
(1) the deposit of all support payments received by | ||
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(2) the deposit of other funds including, but not | ||
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(3) the deposit of any interest accrued by the | ||
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(4) the disbursement of such payments to obligees or | ||
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(5) the disbursement of funds to payors or obligors | ||
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(b) (Blank).
(Source: P.A. 92-44, eff. 7-1-01; 93-20, eff. 6-20-03.)
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(305 ILCS 5/12-8.2) Sec. 12-8.2. Medical Assistance Dental Reimbursement Revolving Fund. There is created a revolving fund to be known as the Medical Assistance Dental Reimbursement Revolving Fund, to be held by the Director of the Department of Healthcare and Family Services, outside of the State treasury, for the following purposes: (1) The deposit of all funds to pay for dental | ||
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(2) The deposit of any interest accrued by the | ||
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(3) The payment of amounts to enrolled dental service | ||
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(Source: P.A. 96-1123, eff. 1-1-11.) |
(305 ILCS 5/12-9) (from Ch. 23, par. 12-9) Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The Public Aid Recoveries Trust Fund shall consist of (1) recoveries by the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) authorized by this Code in respect to applicants or recipients under Articles III, IV, V, and VI, including recoveries made by the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) from the estates of deceased recipients, (2) recoveries made by the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) in respect to applicants and recipients under the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act, (2.5) recoveries made by the Department of Healthcare and Family Services in connection with the imposition of an administrative penalty as provided under Section 12-4.45, (3) federal funds received on behalf of and earned by State universities, other State agencies or departments, and local governmental entities for services provided to applicants or recipients covered under this Code, the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act, (3.5) federal financial participation revenue related to eligible disbursements made by the Department of Healthcare and Family Services from appropriations required by this Section, and (4) all other moneys received to the Fund, including interest thereon. The Fund shall be held as a special fund in the State Treasury. Disbursements from this Fund shall be only (1) for the reimbursement of claims collected by the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) through error or mistake, (2) for payment to persons or agencies designated as payees or co-payees on any instrument, whether or not negotiable, delivered to the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) as a recovery under this Section, such payment to be in proportion to the respective interests of the payees in the amount so collected, (3) for payments to the Department of Human Services for collections made by the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) on behalf of the Department of Human Services under this Code, the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act, (4) for payment of administrative expenses incurred in performing the activities authorized under this Code, the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act, (5) for payment of fees to persons or agencies in the performance of activities pursuant to the collection of monies owed the State that are collected under this Code, the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act, (6) for payments of any amounts which are reimbursable to the federal government which are required to be paid by State warrant by either the State or federal government, and (7) for payments to State universities, other State agencies or departments, and local governmental entities of federal funds for services provided to applicants or recipients covered under this Code, the Children's Health Insurance Program Act, and the Covering ALL KIDS Health Insurance Act. Disbursements from this Fund for purposes of items (4) and (5) of this paragraph shall be subject to appropriations from the Fund to the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid). The balance in this Fund after payment therefrom of any amounts reimbursable to the federal government, and minus the amount anticipated to be needed to make the disbursements authorized by this Section, shall be certified by the Director of Healthcare and Family Services and transferred by the State Comptroller to the Drug Rebate Fund or the Healthcare Provider Relief Fund in the State Treasury, as appropriate, on at least an annual basis by June 30th of each fiscal year. The Director of Healthcare and Family Services may certify and the State Comptroller shall transfer to the Drug Rebate Fund or the Healthcare Provider Relief Fund amounts on a more frequent basis. (Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/12-9.1)
Sec. 12-9.1. DHS Recoveries Trust Fund; uses. The DHS Recoveries Trust
Fund shall consist of (1) recoveries authorized by this Code in respect to
applicants or recipients under Articles III, IV, and VI, including recoveries
from the estates of deceased recipients, (2) payments received by the Illinois
Department of Human Services under Sections 10-3.1, 10-8, 10-10, 10-16, 10-19,
and 12-9 that are required by those Sections to be paid into the DHS Recoveries
Trust Fund, (3) federal financial participation revenue related to eligible disbursements made by the Illinois Department of Human Services from appropriations required by this Section, and (4) amounts received by the Illinois Department of Human Services directly from federal or State grants and intended to be used to pay a portion of the Department's administrative expenses associated with those grants. This Fund shall be held as a special fund in the State Treasury.
Disbursements from the Fund shall be only (1) for the reimbursement of
claims collected by the Illinois Department of Human Services through error
or mistake, (2) for payment to persons or agencies designated as payees or
co-payees on any instrument, whether or not negotiable, delivered to the
Illinois Department of Human Services as a recovery under this Section, such
payment to be in proportion to the respective interests of the payees in the
amount so collected, (3) for payments to non-recipients, or to former
recipients of financial aid of the collections which are made in their behalf
under Article X, (4) for payment to local governmental units of support
payments collected by the Illinois Department of Human Services pursuant to
an agreement under Section 10-3.1, (5) for payment of administrative expenses
incurred in performing the activities authorized by Article X, (6) for payment of administrative expenses associated with the administration of federal or State grants, (7) for payment
of fees to person or agencies in the performance of activities pursuant to the
collection of moneys owed the State, (8) for payments of any amounts which are
reimbursable to the federal government which are required to be paid by State
warrant by either the State or federal government, and (9) for disbursements to
attorneys or advocates for legal representation in an appeal of any claim for
federal Supplemental Security Income benefits before an administrative law
judge as provided for in Section 3-13 of this Code. Disbursements from the
Fund for purposes of items (5), (6), (7), and (9) of this paragraph shall be subject
to appropriations from the Fund to the Illinois Department of Human Services.
Any transfers from the Fund that were required to be made prior to June 19, 2013 (the effective date of Public Act 98-24) shall not be made. (Source: P.A. 100-59, eff. 1-1-18.)
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(305 ILCS 5/12-10) (from Ch. 23, par. 12-10)
Sec. 12-10. DHS Special Purposes Trust Fund; uses. The DHS Special
Purposes Trust Fund, to be held outside the State Treasury by the State
Treasurer as ex-officio custodian, shall consist of (1) any federal grants
received under Section 12-4.6 that are not required by Section 12-5 to be paid
into the General Revenue Fund or transferred into the Local Initiative Fund
under Section 12-10.1 or deposited in the Employment and Training Fund under
Section 12-10.3; (2) grants, gifts or legacies of moneys or securities
received under Section 12-4.18; (3) grants received under Section 12-4.19; and
(4) funds for child care and development services that are not deposited into the Employment and Training Fund under Section 12-10.3. Disbursements from this
Fund shall be only for the purposes authorized by the aforementioned Sections.
Disbursements from this Fund shall be by warrants drawn by the State
Comptroller on receipt of vouchers duly executed and certified by the Illinois
Department of Human Services, including payment to the Health Insurance
Reserve Fund for group insurance costs at the rate certified by the Department
of Central Management Services. In addition to any other transfers that may be provided for by law, the State Comptroller shall direct and the State Treasurer shall transfer from the DHS Special Purposes Trust Fund into the Governor's Grant Fund such amounts as may be directed in writing by the Secretary of Human Services.
In addition to any other transfers that may be provided for by law, the State Comptroller shall direct and the State Treasurer shall transfer from the DHS Special Purposes Trust Fund into the Employment and Training fund such amounts as may be directed in writing by the Secretary of Human Services.
(Source: P.A. 102-16, eff. 6-17-21; 103-363, eff. 7-28-23.)
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(305 ILCS 5/12-10.1) (from Ch. 23, par. 12-10.1)
Sec. 12-10.1.
Local Initiative Fund - Uses.
There is hereby created the Local Initiative Fund in the
State Treasury. The Local Initiative Fund is created for the purpose of
receiving and disbursing monies in accordance with the provisions of the
Social Services Block Grant of the federal Social Security Act and related
rules and regulations,
as now or hereafter amended, governing the use of such monies.
Expenditures from the Local Initiative Fund shall be made for services
contained in the Projected Expenditure Report required of the State
under the Social Services Block Grant of the federal
Social Security Act. The Local Initiative
Fund shall be administered by the Illinois Department, which
shall expend monies appropriated from such fund by the Illinois General
Assembly for the purchase and provision of social services. The Illinois
Department shall execute a written contract for the purchase
of social services from persons qualified to provide such
services. Such contract
shall be filed with the Illinois Department and the State
Comptroller.
There shall be paid into the Local Initiative Fund the following monies:
1. Federal funds paid to the State as reimbursement for expenditures
from the Local Initiative Fund made according to the provisions of the
federal Social Services Block Grant.
2. Payments by the Illinois Department for the purpose of
reimbursing the Local Initiative Fund for expenditures for services not
approved for federal reimbursement under the Social Security Block Grant of
the federal Social Security Act either by the Illinois Department or by the
federal Department of Health and Human Services. Such
payments shall be made by the Illinois Department in the
amount that the Director of the Illinois Department has
determined was not caused by the failure of a provider of services to comply
with the provisions of a service contract or the provisions of the Social
Services Block Grant of the federal Social Security Act and related rules
and regulations as now or hereafter amended. Any such expenditures for
services not approved for federal reimbursement which are subsequently paid
into the Social Services Block Grant Fund shall be transferred into
the General Revenue Fund.
(Source: P.A. 89-507, eff. 7-1-97.)
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(305 ILCS 5/12-10.2) (from Ch. 23, par. 12-10.2)
Sec. 12-10.2.
The Child Support Enforcement Trust Fund.
(a) The Child Support Enforcement Trust Fund, to be held by
the State Treasurer as ex-officio custodian outside the State Treasury,
pursuant to the Child Support Enforcement Program established by Title
IV-D of the Social Security Act, shall consist of the following, through June
30, 2002:
(1) all support payments assigned to the Illinois | ||
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(2) all support payments received by the Illinois | ||
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(3) all federal grants received by the Illinois | ||
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(4) incentive payments received by the Illinois | ||
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(5) incentive payments retained by the Illinois | ||
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(6) all fees charged by the Department for child | ||
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(7) all amounts appropriated by the General Assembly | ||
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(8) any gifts, grants, donations, or awards from | ||
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(a-5) On and after July 1, 2002, the Child Support Enforcement Trust Fund
shall
consist of the following:
(1) all support payments assigned to the Illinois | ||
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(2) all support payments received by the Illinois | ||
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(3) all federal grants received by the Illinois | ||
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(4) incentive payments received by the Illinois | ||
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(5) incentive payments retained by the Illinois | ||
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(6) all fees charged by the Department for child | ||
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(7) all amounts appropriated by the General Assembly | ||
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(8) any gifts, grants, donations, or awards from | ||
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(b) Disbursements from this Fund shall be only for the following
purposes:
(1) for the reimbursement of funds received by the | ||
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(2) for payments to non-recipients, current | ||
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(3) for any other payments required by law to be paid | ||
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(4) for payment of any administrative expenses | ||
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(5) for the reimbursement of the Public Assistance | ||
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(6) for the payment of incentive amounts owed to | ||
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(7) for the payment of incentive amounts owed to | ||
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(8) for payments of any amounts which are | ||
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Disbursements from this Fund shall be by warrants drawn by the State
Comptroller on receipt of vouchers duly executed and certified by the Illinois
Department or any other State agency that receives an appropriation from the
Fund.
(c) The Illinois Department's child support administrative expenses, as
defined in Section 12-10.2a, that are incurred after fiscal year 2002 shall be
paid only as provided in that Section.
(Source: P.A. 91-212, eff. 7-20-99; 91-400, eff. 7-30-99; 91-712, eff.
7-1-00; 92-44, eff. 7-1-01; 92-570, eff. 6-26-02; 92-651, eff. 7-11-02.)
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(305 ILCS 5/12-10.2a)
Sec. 12-10.2a. Child Support Administrative Fund.
(a) Beginning July 1, 2002, the Child Support Administrative Fund is created
as a special fund in
the State treasury. Moneys in the Fund may be used, subject to appropriation,
only for the Department of Healthcare and Family Services' (formerly Department of Public Aid's) child support administrative expenses,
as defined in this Section.
(a-5) Moneys in the Child Support Administrative Fund shall consist of the
following:
(1) all federal grants received by the Illinois | ||
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(2) incentive payments received by the Illinois | ||
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(3) incentive payments retained by the Illinois | ||
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(4) all fees charged by the Department for child | ||
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(5) all amounts appropriated by the General Assembly | ||
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(6) any gifts, grants, donations, or awards from | ||
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(a-10) The moneys identified in subsection (a-5) of this Section shall
include
moneys receipted on or after July 1, 2002, regardless of the fiscal year in
which the
moneys were earned.
(b) As used in this Section, "child support administrative expenses" means
administrative expenses, including payment to the Health Insurance Reserve Fund
for group insurance costs at the rate certified by the Department of Central
Management Services, except those required to be paid from the General Revenue
Fund, including personal and contractual services, incurred by the Department of Healthcare and Family Services (formerly Department
of Public Aid), either directly or under its contracts with SDU contractors as
defined in Section 10-26.2, in performing activities authorized
by Article X of this Code, and including appropriations to other State
agencies or offices. The term includes expenses incurred by the
Department of Healthcare and Family Services (formerly
Department of Public Aid) in administering the Child Support Enforcement Trust
Fund and the State Disbursement Unit Revolving Fund.
(c) Child support administrative expenses incurred in fiscal year 2003 or
thereafter shall be paid only from moneys appropriated
from
the Child Support Administrative Fund.
(d) Before April 1, 2003 and before April 1 of each year thereafter, the
Department of Healthcare and Family Services (formerly Department of Public Aid) shall provide notification to the General Assembly of
the
amount of
the Department's child support administrative expenses expected to be incurred
during the fiscal year beginning on the next July 1, including the estimated
amount required for the operation of the State
Disbursement Unit, which shall be separately identified in the annual
administrative appropriation.
(e) For the fiscal year beginning July 1, 2002 and for each fiscal year
thereafter, the State Comptroller and the State Treasurer shall transfer from
the Child Support Enforcement Trust Fund to the Child Support Administrative
Fund amounts as determined by the Department necessary to enable the Department
to meet its child support
administrative expenses for the then-current fiscal year. For any fiscal year,
the State Comptroller and the State Treasurer may not transfer more than the
total amount appropriated for the Department's child support
administrative expenses for that fiscal year.
(f) By December 1, 2001, the Illinois Department shall provide a corrective
action plan to the General Assembly regarding the establishment of accurate
accounts in the Child Support Enforcement Trust Fund. The plan shall include
those tasks that may be required to establish accurate accounts, the estimated
time for completion of each of those tasks and the plan, and the estimated cost
for completion of each of the tasks and the plan.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/12-10.3) (from Ch. 23, par. 12-10.3)
Sec. 12-10.3. Employment and Training Fund; uses.
(a) The Employment and Training Fund is hereby created in the State
Treasury for the purpose of receiving and disbursing moneys in accordance
with the provisions of Title IV-A of the federal Social Security Act; the Food Stamp
Act, Title 7 of the United States Code; and related rules and regulations
governing the use of those moneys for the purposes of providing employment
and training services, supportive services, cash assistance payments, short-term non-recurrent payments, and other related social services. Beginning in fiscal year 2022, the Employment and Training Fund may receive revenues from State, federal, and private sources related to child care services and programs.
(b) All federal funds received by the Illinois Department as
reimbursement for expenditures for employment and training programs made by
the Illinois Department from grants, gifts, or legacies as provided in
Section 12-4.18 or by an entity other than the Department, and all federal funds received from the Emergency Contingency Fund for State Temporary Assistance for Needy Families Programs established by the American Recovery and Reinvestment Act of 2009,
shall be deposited into the Employment and Training Fund.
(c) Except as provided in subsection (d) of this Section, the
Employment and Training Fund shall be administered by the Illinois
Department, and the Illinois Department may make payments from the
Employment and Training Fund to clients or to public and private entities on behalf of clients for employment and training services, supportive services, cash assistance payments, short-term non-recurrent payments, child care services and child care related programs, and other related social services consistent with the purposes authorized under this Code.
(d) (Blank).
(e) The Illinois Department shall execute a written grant agreement when
purchasing employment and training services from entities qualified to
provide services under
the programs.
(Source: P.A. 102-16, eff. 6-17-21.)
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(305 ILCS 5/12-10.4) Sec. 12-10.4. Juvenile Rehabilitation Services Medicaid Matching Fund. There is created in the State Treasury the Juvenile Rehabilitation Services Medicaid Matching Fund. Deposits to this Fund shall consist of all moneys received from the federal government for behavioral health services secured by counties pursuant to an agreement with the Department of Healthcare and Family Services with respect to Title XIX of the Social Security Act or under the Children's Health Insurance Program pursuant to the Children's Health Insurance Program Act and Title XXI of the Social Security Act for minors who are committed to mental health facilities by the Illinois court system and for residential placements secured by the Department of Juvenile Justice for minors as a condition of their aftercare release. Disbursements from the Fund shall be made, subject to appropriation, by the Department of Healthcare and Family Services for grants to the Department of Juvenile Justice and those counties which secure behavioral health services ordered by the courts and which have an interagency agreement with the Department and submit detailed bills according to standards determined by the Department. On January 1, 2026, or as soon thereafter as practical, the State Comptroller shall direct and the State Treasurer shall transfer the remaining balance from the Juvenile Rehabilitation Services Medicaid Matching Fund into the Public Aid Recoveries Trust Fund. Upon completion of the transfer, the Juvenile Rehabilitation Services Medicaid Matching Fund is dissolved, and any future deposits due to that Fund and any outstanding obligations or liabilities of that Fund shall pass to the Public Aid Recoveries Trust Fund. (Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/12-10.5)
Sec. 12-10.5. Medical Special Purposes Trust Fund.
(a) The Medical Special Purposes Trust Fund ("the Fund") is created.
Any grant, gift, donation, or legacy of money or securities that the
Department of Healthcare and Family Services is authorized to receive under Section 12-4.18 or
Section 12-4.19 or any monies from any other source, and that are dedicated for functions connected with the
administration of any medical program administered by the Department, shall
be deposited into the Fund. All federal moneys received by the Department as
reimbursement for disbursements authorized to be made from the Fund shall also
be deposited into the Fund. In addition, federal moneys received on account
of State expenditures made in connection with obtaining compliance with the
federal Health Insurance Portability and Accountability Act (HIPAA) shall be
deposited into the Fund.
(b) No moneys received from a service provider or a governmental or private
entity that is enrolled with the Department as a provider of medical services
shall be deposited into the Fund.
(c) Disbursements may be made from the Fund for the purposes connected with
the grants, gifts, donations, legacies, or other monies deposited into the Fund, including,
but not limited to, medical quality assessment projects, eligibility population
studies, medical information systems evaluations, and other administrative
functions that assist the Department in fulfilling its health care mission
under any medical program administered by the Department.
(Source: P.A. 97-48, eff. 6-28-11; 97-689, eff. 6-14-12.)
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(305 ILCS 5/12-10.6)
Sec. 12-10.6.
Medicaid Buy-In Program Revolving Fund.
(a) The Medicaid Buy-In Program Revolving Fund is created as a special fund
in the State treasury. The Fund shall consist of cost-sharing payments made by
individuals pursuant to the Medicaid Buy-In Program established under paragraph
11 of Section 5-2 of this Code. All earnings on moneys in the Fund shall be
credited to the Fund.
(b) Moneys in the Fund shall be appropriated to the Department to pay the
costs of administering the Medicaid Buy-In Program, including payments for
medical assistance benefits provided to Program participants. The Department
shall adopt rules specifying the particular purposes for which the moneys in
the Fund may be spent.
(Source: P.A. 92-163, eff. 7-25-01; 92-651, eff. 7-11-02.)
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(305 ILCS 5/12-10.6a) Sec. 12-10.6a. The Electronic Health Record Incentive Fund. (a) The Electronic Health Record Incentive Fund is a special fund created in the State treasury. All federal moneys received by the Department of Healthcare and Family Services for payments to qualifying health care providers to encourage the adoption and use of certified electronic health records technology pursuant to paragraph 1903(t)(1) of the Social Security Act, shall be deposited into the Fund. (b) Disbursements from the Fund shall be made at the direction of the Director of Healthcare and Family Services to qualifying health care providers, in amounts established under applicable federal regulation (42 CFR 495 et seq.), in order to encourage the adoption and use of certified electronic health records technology. (c) On January 1, 2025, or as soon thereafter as practical, the State Comptroller shall direct and the State Treasurer shall transfer the remaining balance from the Electronic Health Record Incentive Fund into the Public Aid Recoveries Trust Fund. Upon completion of the transfer, the Electronic Health Record Incentive Fund is dissolved, and any future deposits due to that Fund and any outstanding obligations or liabilities of that Fund shall pass to the Public Aid Recoveries Trust Fund. (Source: P.A. 103-593, eff. 6-7-24.) |
(305 ILCS 5/12-10.7)
Sec. 12-10.7. The Health and Human Services Medicaid Trust Fund. The Health and Human Services Medicaid Trust Fund shall consist of (i) moneys appropriated or transferred into the Fund, pursuant to statute, (ii) federal financial participation moneys received pursuant to expenditures from the Fund, and (iii) the interest earned on moneys in the Fund. Subject to appropriation, the moneys in the Fund shall be used by a State agency for such purposes as that agency may, by the appropriation language, be directed.
(Source: P.A. 102-1071, eff. 6-10-22.) |
(305 ILCS 5/12-10.7a)
Sec. 12-10.7a. The Money Follows the Person Budget Transfer Fund is hereby created as a special fund in the State treasury. (a) Notwithstanding any State law to the contrary, the following moneys shall be deposited into the Fund: (1) enhanced federal financial participation funds | ||
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(2) federal financial participation funds related to | ||
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(2.5) other federal funds awarded for a Money | ||
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(3) deposits made via the voucher-warrant process | ||
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(4) deposits made via the voucher-warrant process | ||
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(5) interest earned on moneys in the Fund; and (6) all other moneys received by the Fund from any | ||
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(b) Subject to appropriation, moneys in the Fund may be used by the Department of Healthcare and Family Services for reimbursement or payment for: (1) expenses related to rebalancing long-term care | ||
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(2) expenses for community-based services for | ||
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(3) expenses for institutional long-term care | ||
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(4) expenses, including operational, administrative, | ||
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Expenses reimbursed or paid on behalf of other agencies by the Department of Healthcare and Family Services under this subsection shall be pursuant to an interagency agreement and allowable under a Money Follows the Person demonstration project or initiative, as approved by the federal Centers for Medicare and Medicaid Services and codified at 20 ILCS 2407/51 et seq.
(Source: P.A. 103-8, eff. 6-7-23.) |
(305 ILCS 5/12-10.8)
Sec. 12-10.8. (Repealed).
(Source: P.A. 95-707, eff. 1-11-08. Repealed by P.A. 97-820, eff. 7-17-12.)
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(305 ILCS 5/12-10.9)
Sec. 12-10.9. (Repealed).
(Source: P.A. 95-744, eff. 7-18-08. Repealed by P.A. 97-820, eff. 7-17-12.)
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(305 ILCS 5/12-10.10) Sec. 12-10.10. HFS Technology Initiative Fund. (a) The HFS Technology Initiative Fund is hereby created as a trust fund within the State treasury with the State Treasurer as the ex-officio custodian of the Fund. (b) The Department of Healthcare and Family Services may accept and receive grants, awards, gifts, bequests, or other moneys from any source, public or private, in support of information technology initiatives. Those moneys received in support of information technology initiatives, and any interest earned thereon, shall be deposited into the HFS Technology Initiative Fund. (c) Moneys in the Fund may be used by the Department of Healthcare and Family Services for the purpose of making grants associated with the development and implementation of information technology projects or paying for operational expenses of the Department of Healthcare and Family Services related to such projects. The Department of Healthcare and Family Services may use moneys in the Fund to pay for administrative, operational, and project expenses of the Illinois Health and Human Services Innovation Incubator (HHSi2) project. Notwithstanding any provision of law to the contrary, the Department of Human Services shall have the authority to satisfy all Fiscal Year 2023 outstanding expenditure obligations or liabilities payable from the Fund pursuant to Section 25 of the State Finance Act. (d) The Department of Healthcare and Family Services, in consultation with the Department of Innovation and Technology, shall use the funds deposited into the HFS Technology Initiative Fund to pay for information technology solutions either provided by Department of Innovation and Technology or arranged or coordinated by the Department of Innovation and Technology.
(Source: P.A. 103-8, eff. 7-1-23.) |
(305 ILCS 5/12-11) (from Ch. 23, par. 12-11)
Sec. 12-11. Deposits by State Treasurer. The State Treasurer shall
deposit moneys received by him as ex-officio custodian of the Child
Support Enforcement Trust Fund and the DHS Special Purposes Trust Fund in
banks or savings and loan associations which have been approved by him
as State Depositaries under the Deposit of State Moneys Act, and
with respect to such moneys shall be entitled to the
same rights and privileges as are provided by such Act with
respect to moneys in the treasury of the State of Illinois.
(Source: P.A. 99-933, eff. 1-27-17.)
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(305 ILCS 5/12-12) (from Ch. 23, par. 12-12)
Sec. 12-12. Collection of claims; enforcement of penalty provisions. (a) The Illinois Department shall pursue the legal procedure necessary to
collect the claims and enforce the penalty provisions provided in any
Section or Article of this Code relative to applicants and recipients of
public aid. The Attorney General, at the request of the Illinois
Department, shall take the necessary proceedings and represent the
Illinois Department in any matter arising in connection with such claims
or enforcement of penalty provisions. (b) In matters concerning the recovery of overpayments for benefits provided by the Department of Human Services, the Department shall send a recipient written notice and a demand for payment of any amount in overpaid benefits owed within 5 years after the Department's right to collect the overpayment first accrued. The Department of Human Services shall issue such notice by certified mail to the recipient's last known mailing address. Actions brought under this subsection by the Attorney General for the recovery of overpayments shall be commenced within 10 years after the date upon which such notice was sent.
(Source: P.A. 103-485, eff. 1-1-24.)
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(305 ILCS 5/12-12.1)
Sec. 12-12.1.
Deadbeats most wanted list.
(a) The Director may disclose a "deadbeats most wanted list" of
individuals who are in arrears in their child support obligations under an
Illinois court order or administrative order. The list shall include only
those persons who are in arrears in an amount greater than $5,000 (or such
greater amount as established by the Department by rule). The list shall
not exceed 200 individuals at any point. The list shall include the
individual's name and address, the amount of any child support arrearage,
and any other information deemed appropriate by the Department.
(b) At least 90 days before the disclosure under subsection (a) of the
name of an individual who is in arrears in his or her child support
obligations, the Director shall mail a written notice to the individual by
certified mail addressed to the individual's last known address. The notice
shall detail the amount of the arrearage and the Department's intent to
disclose the arrearage. If the arrearage is not paid 60 days after the notice
was delivered to the individual or the Department has been notified that
delivery was refused, and the individual has not, since the mailing of the
notice, entered into a written agreement with the Department for payment
of the arrearage, the Director may disclose the individual's arrearage under
subsection (a).
(c) An individual in arrears in his or her child support obligations
under an Illinois court order or administrative order is not subject to
disclosure under subsection (a) if (1) a written agreement for payment
exists between the individual and the Department or (2) the arrearage is
the subject of an administrative hearing, administrative review, or judicial
review.
(d) The list shall be available for public inspection at the Department
or by other means of publication, including the Internet.
(e) A disclosure made by the Director in a good faith effort to
comply with this Section may not be considered a violation of any
confidentiality laws.
(Source: P.A. 92-373, eff. 7-1-02.)
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(305 ILCS 5/12-13) (from Ch. 23, par. 12-13)
Sec. 12-13. Rules and regulations. The Department shall make all rules and
regulations and take such action as may be necessary or desirable for carrying
out the provisions of this Code, to the end that its spirit and purpose may be
achieved and the public aid programs administered efficiently throughout the
State. However, the rules and regulations shall not provide that payment for
services rendered to a specific recipient by (i) a person licensed under
the
Medical Practice Act of 1987, whether under a general or limited license,
(ii) a
person licensed or registered under other laws of this State to provide dental,
optometric, or pediatric care,
or (iii) a licensed clinical social worker
may be authorized only when services are
recommended for that recipient by a person licensed to practice medicine in all
its branches.
Whenever a rule of the Department requires that an applicant or
recipient verify information submitted to the Department, the rule, in
order to make the public fully aware of what information is required for
verification, shall specify the acceptable means of verification or shall
list examples of acceptable means of verification.
The provisions of the Illinois Administrative Procedure Act are hereby
expressly adopted and incorporated herein, and shall apply to all
administrative rules and procedures of the Illinois Department under this Act,
except that Section 5-35 of the Illinois Administrative Procedure Act relating
to procedures for rule-making does not apply to the adoption of any rule
required by federal law in connection with which the Illinois Department is
precluded by law from exercising any discretion, and the requirements of the
Administrative Procedure Act with respect to contested cases are not applicable
to (1) hearings involving eligibility of applicants or recipients of public
aid or (2) support hearings involving responsible relatives.
(Source: P.A. 95-518, eff. 8-28-07.)
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(305 ILCS 5/12-13.05)
Sec. 12-13.05. Rules for Temporary Assistance for Needy Families.
All rules regulating the Temporary Assistance for Needy Families program and
all other rules regulating the amendatory changes to this Code made by this
amendatory Act of 1997 shall be promulgated pursuant to this Section.
(Source: P.A. 94-416, eff. 1-1-06.)
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(305 ILCS 5/12-13.1)
Sec. 12-13.1. Inspector General.
(a) The Governor shall appoint, and the Senate shall confirm, an Inspector
General who shall function within the Illinois Department of Public Aid (now Healthcare and Family Services) and
report to the Governor. The term of the Inspector General shall expire on the
third Monday of January, 1997 and every 4 years thereafter.
(b) In order to prevent, detect, and eliminate fraud, waste, abuse,
mismanagement, and misconduct, the Inspector General shall oversee the
Department of Healthcare and Family Services' and the Department on Aging's integrity
functions, which include, but are not limited to, the following:
(1) Investigation of misconduct by employees, | ||
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(2) Prepayment and post-payment audits of medical | ||
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(3) Monitoring of quality assurance programs | ||
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(4) Quality control measurements of the programs | ||
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(5) Investigations of fraud or intentional program | ||
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(6) Actions initiated against contractors, vendors, | ||
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(A) Violations of the medical assistance program | ||
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(B) Sanctions against providers brought in | ||
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(C) Recoveries of assessments against hospitals | ||
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(D) Sanctions mandated by the United States | ||
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(E) Violations of contracts related to any | ||
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(7) Representation of the Department of Healthcare | ||
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(b-5) At the request of the Secretary of Human Services, the Inspector
General shall, in relation to any function performed by the Department of Human
Services as successor to the Department of Public Aid, exercise one or more
of the powers provided under this Section as if those powers related to the
Department of Human Services; in such matters, the Inspector General shall
report his or her findings to the Secretary of Human Services.
(c) Notwithstanding, and in addition to, any other
provision of law, the Inspector General shall have access to all information, personnel
and facilities of the
Department of Healthcare and Family Services and the Department of
Human Services (as successor to the Department of Public Aid), their employees, vendors, contractors and medical providers and any federal,
State or local governmental agency that are necessary to perform the duties of
the Office as directly related to public assistance programs administered by
those departments. No medical provider shall
be compelled, however, to provide individual medical records of patients who
are not clients of the programs administered by the Department of Healthcare and
Family Services. State and local
governmental agencies are authorized and directed to provide the requested
information, assistance or cooperation.
For purposes of enhanced program integrity functions and
oversight, and to the extent consistent with applicable
information and privacy, security, and disclosure laws, State
agencies and departments shall provide the Office of Inspector General access to confidential and other information and data, and the Inspector General is authorized to enter into agreements with appropriate federal agencies and departments to secure similar data. This includes, but is not limited to, information pertaining to: licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records. The Inspector General shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Inspector General shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies shall share data necessary for recipient and vendor screening, review, and investigation, including but not limited to vendor payment and recipient eligibility verification. The Inspector General shall develop, in cooperation with other State and federal agencies and departments, and in compliance with applicable federal laws and regulations, appropriate and effective
methods to share such data. The Inspector General shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the
Department of Revenue; the Department of Public Health; the
Department of Human Services; and the Department of Financial and Professional Regulation. The Inspector General shall have the authority to deny payment, prevent overpayments, and recover overpayments. The Inspector General shall have the authority to deny or
suspend payment to, and deny, terminate, or suspend the
eligibility of, any vendor who fails to grant the Inspector
General timely access to full and complete records, including records of recipients under the medical assistance program for the most recent 6 years, in accordance with Section 140.28 of Title 89 of the Illinois Administrative Code, and other information for the purpose of audits, investigations, or other program integrity functions, after reasonable written request by the Inspector General. (d) The Inspector General shall serve as the
Department of Healthcare and Family Services'
primary liaison with law enforcement,
investigatory and prosecutorial agencies, including but not limited to the
following:
(1) The Department of State Police.
(2) The Federal Bureau of Investigation and other | ||
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(3) The various Inspectors General of federal | ||
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(4) The various Inspectors General of any other State | ||
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(5) The Offices of the several United States | ||
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(6) The several State's Attorneys.
(7) The offices of the Centers for Medicare and | ||
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The Inspector General shall meet on a regular basis with these entities to
share information regarding possible misconduct by any persons or entities
involved with the public aid programs administered by the Department
of Healthcare and Family Services.
(e) All investigations conducted by the Inspector General shall be conducted
in a manner that ensures the preservation of evidence for use in criminal
prosecutions. If the Inspector General determines that a possible criminal act
relating to fraud in the provision or administration of the medical assistance
program has been committed, the Inspector General shall immediately notify the
Medicaid Fraud Control Unit. If the Inspector General determines that a
possible criminal act has been committed within the jurisdiction of the Office,
the Inspector General may request the special expertise of the Department of
State Police. The Inspector General may present for prosecution the findings
of any criminal investigation to the Office of the Attorney General, the
Offices of the several United States Attorneys in Illinois or the several
State's Attorneys.
(f) To carry out his or her duties as described in this Section, the
Inspector General and his or her designees shall have the power to compel
by subpoena the attendance and testimony of witnesses and the production
of books, electronic records and papers as directly related to public
assistance programs administered by the Department of Healthcare and Family Services or
the Department of Human Services (as successor to the Department of Public
Aid). No medical provider shall be compelled, however, to provide individual
medical records of patients who are not clients of the Medical Assistance
Program.
(g) The Inspector General shall report all convictions, terminations, and
suspensions taken against vendors, contractors and medical providers to the
Department of Healthcare and Family Services and to any agency responsible for
licensing or regulating those persons or entities.
(h) The Inspector General shall make annual
reports, findings, and recommendations regarding the Office's investigations
into reports of fraud, waste, abuse, mismanagement, or misconduct relating to
any programs administered by the Department
of Healthcare and Family Services or the Department of Human Services (as successor to the
Department of Public Aid) to the General Assembly and the Governor. These
reports shall include, but not be limited to, the following information:
(1) Aggregate provider billing and payment | ||
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(2) The number of audits of the medical assistance | ||
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(3) The number of prescriptions rejected annually | ||
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(4) Provider sanctions, in the aggregate, including | ||
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(5) A detailed summary of the investigations | ||
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(i) Nothing in this Section shall limit investigations by the
Department of Healthcare and Family Services or the Department of Human Services that may
otherwise be required by law or that may be necessary in their capacity as the
central administrative authorities responsible for administration of their agency's
programs in this
State.
(j) The Inspector General may issue shields or other distinctive identification to his or her employees not exercising the powers of a peace officer if the Inspector General determines that a shield or distinctive identification is needed by an employee to carry out his or her responsibilities. (Source: P.A. 97-689, eff. 6-14-12; 98-8, eff. 5-3-13.)
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(305 ILCS 5/12-13.2)
Sec. 12-13.2.
Two-year financial plans.
(a) On or before September 30, 1994, the Illinois Department shall submit to
the
General Assembly an initial 2-year financial plan with respect to the Illinois
Department's administration and financing of the State's Medicaid program for
fiscal years 1995 and 1996. The Illinois Department shall submit subsequent
2-year financial plans in accordance with this Section. Beginning with
fiscal year 1997, and every second fiscal year thereafter, the Illinois
Department shall submit a financial plan covering a period of 2 fiscal years
not
later than March 1 before the commencement of the first fiscal year to which
the financial plan relates. Each financial plan shall be submitted in
accordance with the procedures set forth in this Section.
(b) Each financial plan for each fiscal year to which it relates shall
contain a description of revenues, liabilities, expenditures, appropriations,
and cash resources and uses.
(c) The Illinois Department shall regularly reexamine the revenue and
expenditure estimates on which each financial plan was based and revise them
as
necessary. The Illinois Department shall promptly notify the General Assembly
of any material change in the revenue or expenditure estimates in the financial
plan. The Illinois Department shall submit to the General Assembly modified
financial plans based on revised revenue or expenditure estimates or for any
other good reason.
(Source: P.A. 88-554, eff. 7-26-94.)
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(305 ILCS 5/12-13.3)
Sec. 12-13.3.
Transitional jobs; pilot program.
Subject to appropriations
or other funding, the Department of Human
Services may establish a pilot program to place hard-to-employ persons,
including
persons who have been released from a county jail or a facility under the
jurisdiction of
the Department of Corrections, in jobs. By rule, the Department shall determine
the
location in which the pilot program is to be implemented and the services to be
provided.
In determining locations for the pilot program, however, the Department shall
give priority to areas of the State in which the concentration of released
offenders is the highest.
The Department may consult with the Department of Corrections in establishing
the pilot
program.
(Source: P.A. 93-208, eff. 7-18-03.)
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(305 ILCS 5/12-13.4) Sec. 12-13.4. Materials on nutritional health. The Department of Human Services, in cooperation with the Department of Public Health, shall develop materials and resources on nutritional health for distribution to new enrollees in the TANF program under Article IV and the Food Stamp program. The Department of Public Health shall develop a video presentation on nutritional health to be shown to new enrollees in the TANF program under Article IV and the Food Stamp program. The Department of Human Services shall develop the materials and resources within 6 months after the effective date of this amendatory Act of the 94th General Assembly and shall provide those materials and resources to all persons who enroll in the TANF program and the Food Stamp program after the materials and resources are developed.
(Source: P.A. 94-433, eff. 1-1-06.) |
(305 ILCS 5/12-14.1) (from Ch. 23, par. 12-14.1)
Sec. 12-14.1.
Audit by Auditor General.
The Auditor General shall conduct
a post audit to determine if the Department has complied with the requirements
of Section 5-5.9 of this Code. The audit required by this Section shall
be in accordance with and subject to the Illinois State Auditing Act as
now and hereafter amended. The Legislative Audit Commission, by resolution,
may make additions or clarifications to the scope or coverage of the audit
required by this Section.
(Source: P.A. 82-664.)
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(305 ILCS 5/12-15) (from Ch. 23, par. 12-15)
Sec. 12-15.
Civil Recoveries.
Any person, firm, corporation, association, agency, institution or other
legal entity who, without intent to violate this Code, obtains benefits
or payments under this Code to which he or it is not entitled, or in a greater
amount than that to which he or it is entitled shall be liable for any excess
benefits or payments received.
The Attorney General, or the State's Attorney in actions involving a local
governmental unit, may initiate court proceedings to recover benefits or
payments obtained under this Code to which a person or entity is not entitled.
(Source: P.A. 82-440.)
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(305 ILCS 5/12-16) (from Ch. 23, par. 12-16)
Sec. 12-16. Public Aid Claims Enforcement Division of Office of Attorney
General. The Public Aid Claims Enforcement Division in the Office of the
Attorney General, established pursuant to the 1949 Code, shall institute in
behalf of the State all court actions referred to it by the Department of Healthcare and Family Services (formerly Illinois Department
of Public Aid) or the Department of Human Services (as successor to the
Illinois Department of Public Aid) under this Code and other laws for the
recovery of financial aid provided under the public aid programs, the
enforcement of obligations of support, and the enforcement of other claims,
penalties and obligations.
The Division shall be staffed with attorneys appointed by the Attorney
General as Special Assistant Attorneys' General whose special duty it shall be
to execute the aforesaid duties. The Assistant Attorneys' General shall be
assigned exclusively to such duties. They may engage only in such political
activities as are not prohibited by the Hatch Political Activity Act, Title 5,
U.S.C.A., Sections 118i et seq.
The Attorney General may request the appropriate State's Attorney of a county
or staff of the Child and Spouse Support Unit established under Section 10-3.1
of this Code to institute any such action in behalf of the State or to assist
the Attorney General in the prosecution of actions instituted by his Office.
(Source: P.A. 95-331, eff. 8-21-07.)
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(305 ILCS 5/12-17) (from Ch. 23, par. 12-17)
Sec. 12-17.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-17.1) (from Ch. 23, par. 12-17.1)
Sec. 12-17.1.
(Repealed).
(Source: P.A. 88-412. Repealed by P.A. 92-111, eff.
1-1-02.)
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(305 ILCS 5/12-17.2) (from Ch. 23, par. 12-17.2)
Sec. 12-17.2.
(Repealed).
(Source: Repealed by P.A. 88-412.)
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(305 ILCS 5/12-17.3) (from Ch. 23, par. 12-17.3)
Sec. 12-17.3.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-17.4) (from Ch. 23, par. 12-17.4)
Sec. 12-17.4.
(Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-17.5) (from Ch. 23, par. 12-17.5)
Sec. 12-17.5.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18) (from Ch. 23, par. 12-18)
Sec. 12-18.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.1) (from Ch. 23, par. 12-18.1)
Sec. 12-18.1.
(Repealed).
(Source: P.A. 88-412. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.1a) (from Ch. 23, par. 12-18.1a)
Sec. 12-18.1a.
(Repealed).
(Source: P.A. 77-352. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.2) (from Ch. 23, par. 12-18.2)
Sec. 12-18.2.
(Repealed).
(Source: P.A. 81-1085. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.3) (from Ch. 23, par. 12-18.3)
Sec. 12-18.3.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.4) (from Ch. 23, par. 12-18.4)
Sec. 12-18.4.
(Repealed).
(Source: P.A. 81-1509. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.5) (from Ch. 23, par. 12-18.5)
Sec. 12-18.5.
(Repealed).
(Source: P.A. 78-363. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.6) (from Ch. 23, par. 12-18.6)
Sec. 12-18.6.
(Repealed).
(Source: P.A. 81-230. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.8) (from Ch. 23, par. 12-18.8)
Sec. 12-18.8.
(Repealed).
(Source: P.A. 78-363. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-18.9) (from Ch. 23, par. 12-18.9)
Sec. 12-18.9.
(Repealed).
(Source: P.A. 78-363. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-19) (from Ch. 23, par. 12-19)
Sec. 12-19.
County
welfare services committees; membership.
If a county welfare services committee is formed in a county of less than 3,000,000 population, the committee may consist of not more than 10 members appointed by the Illinois
Department and the following members, ex-officio: the state's attorney
and
the chairman of the county board. The terms of the state's
attorney and the chairman of the county board shall be co-extensive with
their terms of office. The terms of the Illinois Department appointees
shall be as specified in this Section.
In counties of 3,000,000 or more population, if a county
welfare services
committee is formed, it may consist of not more than 33
members appointed by the Illinois Department
and the president of the county board of commissioners, ex-officio. The
term of the president of the county board of commissioners shall be
co-extensive with his term of office. The terms of the Illinois Department
appointees shall be as specified in this Section.
The Illinois Department shall make its appointments from a list of
nominees submitted with the advice and consent of the county board by the
presiding officer of the county board of each county. If the county board
fails or refuses to submit a list of nominees, the Illinois Department may
make appointments from among the residents of the county.
The Illinois Department and the county boards shall include a balanced
representation of recipients, service providers, representatives of community
and welfare advocacy groups, representatives of local governments dealing
with public aid, and representatives of the general public on all county
welfare services committees appointed by the Illinois Department or on lists
of nominees submitted by the presiding officers of the county boards.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-19.1) (from Ch. 23, par. 12-19.1)
Sec. 12-19.1.
Appointments-Terms-Vacancy.
In counties of less than 3 million population, the Illinois Department
shall appoint 3 members of the County Welfare Services Committee on July 1,
1967; 4 members on July 1, 1968; and 3 members on July 1, 1969, as
successors respectively to the members whose terms expire on such dates. In
counties of 3 million or more population, the Illinois Department shall
appoint 4 members of the Committee on July 1, 1967; 4 on July 1, 1968; and
4 on July 1, 1969, as successors respectively to the members whose terms
expire on such dates, and shall on July 1, 1971, appoint 25 members, 7 of
whom shall serve for a term of 1 year, 7 of whom shall serve for 2 years,
and 11 of whom shall serve for 3 years as designated by the Illinois
Department at the time of appointment. Thereafter, upon the expiration of
any term, successors shall be appointed in like manner as the original
appointees, for a term of 3 years and until their successors are appointed.
Vacancies in office shall be filled in like manner as original appointments
but appointment shall be only for the remainder of the term of the vacancy.
(Source: P.A. 77-522.)
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(305 ILCS 5/12-19.2) (from Ch. 23, par. 12-19.2)
Sec. 12-19.2.
Organization of committee.
The county welfare services committee, at its first meeting in each
calendar year, shall organize by electing from its membership a chairman and
vice chairman. These officers shall serve a
term of one year and until their successors are elected but neither may
serve more than 3 consecutive terms. The Department of Human Services local
office administrator shall act as the executive secretary of the committee and assist it in
fulfilling its responsibilities in the manner the committee
designates. The committee may request the assistance of other members of the
staff of the County Department to perform duties the committee
designates. The committee shall provide rules for transacting its business
and keeping records thereof. It shall hold as many meetings during each
calendar year as may be necessary to fulfill committee responsibilities. In
counties of less than 3,000,000 population, meetings may be
called by the
chairman or any 3 members. In counties of 3,000,000 or more
population,
meetings may be called by the chairman or any 11 members. The members of
the committee shall receive no compensation for their services but shall be
reimbursed for actual and necessary traveling and other expenses incurred
in the performance of their duties.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-19.3) (from Ch. 23, par. 12-19.3)
Sec. 12-19.3.
Information to committee.
The County Department shall furnish each member of the County Welfare
Services Committee, upon such member's request, a copy of the existing
regulations and of all changes of regulations pertaining to any of the
public aid programs, and of rulings handed down by the Illinois Department
or the courts on review, affecting or interpreting such regulations.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-19.4) (from Ch. 23, par. 12-19.4)
Sec. 12-19.4.
(Repealed).
(Source: P.A. 82-783. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-19.5) (from Ch. 23, par. 12-19.5)
Sec. 12-19.5.
Advisory functions; reports.
The County Welfare Services
Committee shall advise the County Department in relation to the
administration of its functions and duties. The Committee shall also advise
the Illinois Department on all matters pertaining to public aid in the
county, recommend the development of community welfare programs it may deem
necessary and stimulate community interest in these programs and their
proper organization, survey economic and social welfare conditions and
employment opportunities, and perform any other duties as the Illinois
Department may prescribe.
The Committee shall submit to the Illinois Department periodic reports
of its activities, findings, and recommendations at the times
and in the manner as the Department may direct.
The Committee shall review the quality of services provided to
recipients of and applicants for assistance and other social services and
the quality of relations between recipients and applicants and employees of
the Illinois Department and County Departments. The Committee shall report
annually to the Illinois Department its findings in these matters and its
recommendations for improvement.
(Source: P.A. 87-528.)
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(305 ILCS 5/12-20) (from Ch. 23, par. 12-20)
Sec. 12-20.
(Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-21) (from Ch. 23, par. 12-21)
Sec. 12-21.
Administration in local Governmental Units.
Administration of the public aid programs for which responsibility is
vested in local governmental units under Article VI shall be in
accordance with the provisions of Sections 12-21.1 to 12-21.20,
inclusive.
However, all public aid programs which provide medical services or assistance
to non-residents of the State of Illinois which, but for the aspect of residency,
would be a township responsibility, shall be administered by the Illinois
Department pursuant to Sections 12-4 to 12-12, inclusive, of this Article,
and pursuant to the Department's authorized rules and regulations.
(Source: P.A. 81-1509.)
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(305 ILCS 5/12-21.1) (from Ch. 23, par. 12-21.1)
Sec. 12-21.1.
Supervisors of general assistance in counties not under
township organization - Other staffing. In counties not under township organization,
the presiding officer of
the county board, with the advice and consent of the County Board, shall
designate a Supervisor of General Assistance for the county and appoint
such other employees as may be necessary to provide public aid under
Article VI. The County Board shall prescribe the compensation
and duties of the Supervisor and other employees.
(Source: P.A. 81-1085.)
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(305 ILCS 5/12-21.2) (from Ch. 23, par. 12-21.2)
Sec. 12-21.2.
Supervisors of general assistance in counties under
township organization - Other staffing. In counties under township organization,
the supervisors of the
respective towns therein shall be ex officio Supervisors of General
Assistance of their towns. The Supervisor of General Assistance shall
appoint such other employees as may be necessary to provide public aid
under Article VI and prescribe their compensation and duties.
(Source: P.A. 81-1085.)
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(305 ILCS 5/12-21.3) (from Ch. 23, par. 12-21.3)
Sec. 12-21.3.
(Repealed).
(Source: P.A. 83-333. Repealed by P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-21.4) (from Ch. 23, par. 12-21.4)
Sec. 12-21.4.
Supervisor of general assistance in incorporated town which has superseded
a civil township-Other staff.
In an incorporated town which has superseded a civil township, the
supervisor of such incorporated town shall be ex officio Supervisor of
General Assistance. The governing body of the incorporated town may by
ordinance provide for the appointment of other employees as may be
necessary to provide public aid under Article VI, and fix their
compensation.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-21.5) (from Ch. 23, par. 12-21.5)
Sec. 12-21.5.
Veterans Assistance Commission as local governmental unit.
In counties having less than 3 million inhabitants in which there is
created a County Veterans Assistance Commission, the Superintendent of
Veterans Assistance shall be selected and other employees appointed as provided
in Section 10 of the Military Veterans Assistance Act and the compensation
of the Superintendent and other employees shall be as therein provided.
(Source: P.A. 87-796.)
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(305 ILCS 5/12-21.6) (from Ch. 23, par. 12-21.6)
Sec. 12-21.6.
Compensation and standards of employees of local
governmental units receiving state funds. In any local governmental unit
receiving State funds for public aid
purposes under Article VI, the number and compensation rates
and standards of competence, performance, and tenure of all employees or
other persons paid from public aid funds, including the compensation
rates of the persons serving as or designated as Supervisor of General
Assistance if such person is paid in whole or in part from public aid
funds, shall be subject to review and approval of the Illinois
Department.
(Source: P.A. 81-1085.)
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(305 ILCS 5/12-21.7) (from Ch. 23, par. 12-21.7)
Sec. 12-21.7.
Limitations on political activities.
In any local governmental unit receiving State funds, each employee
whose duties pertain to determination of eligibility for or the amount
of public aid is prohibited from engaging in at any time, whether during
or outside of regular working hours, any of the following activities:
1. Using or threatening to use the influence or authority of his
position to coerce or to persuade any person to follow any course of
political action.
2. Soliciting money from any person for any political purpose.
3. Selling or distributing tickets for political meetings.
4. Assisting at the polls in behalf of any party or party-designated
candidate on any election day.
5. Initiating or circulating petitions on behalf of a candidate.
6. Distributing campaign literature or material in behalf of any
candidate.
Any employee who engages in the foregoing proscribed political
activities shall be subject to immediate discharge in accordance with
the procedures controlling his position. If an employee engages in such
activities at the request or direction of any officer or officers of the
local governmental unit, or if the governmental unit fails to initiate
procedures for the dismissal of an employee who persists in such
activities, the Illinois Department may withhold the payment of any
further State funds to the local governmental unit until the
governmental unit has established that its actions are in full accord
with the objectives of this Section.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/12-21.8) (from Ch. 23, par. 12-21.8)
Sec. 12-21.8.
Duties of supervisors of general assistance.
Except for
the Supervisor of General Assistance who is the Director of the County
Department of Public Aid, the Supervisor of General Assistance shall
receive and pay out moneys raised by taxes or allocated by the State for
public aid purposes and shall provide public aid to all persons eligible
therefor under Article VI of this Code. State and municipal funds for
General Assistance purposes in a city, village or incorporated town of
more than 500,000 population shall be received and disbursed as provided
in Section 12-10.
The Supervisor of General Assistance shall keep such records and
submit annually and at such other times as their respective county
boards, city councils, board of trustees, or board of town trustees may
require, reports relating to the administration of such public aid
programs as are the responsibility of the local governmental unit under
this Code, prepared in such form as may be directed by such agencies.
On or before the 15th day of each calendar month, Supervisors of
General Assistance shall submit to the Illinois Department full itemized
reports of all receipts and expenditures of moneys for public aid and
the costs of administration under Article VI of this Code during the
prior calendar month, together with such other reports as the Illinois
Department may require. The Illinois Department may audit the books and
records dealing with such public aid programs at such times as it deems
necessary.
(Source: P.A. 82-783.)
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(305 ILCS 5/12-21.9) (from Ch. 23, par. 12-21.9)
Sec. 12-21.9.
Limitations on indebtedness.
No indebtedness shall be incurred by any Supervisor of General
Assistance in excess of taxes levied for public aid purposes and
uncollected, or for the payment of which funds are not currently available,
without the consent of the city council or board of trustees, board of town
trustees, or county board, as the case may be.
(Source: P.A. 82-783.)
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(305 ILCS 5/12-21.10) (from Ch. 23, par. 12-21.10)
Sec. 12-21.10.
Default and misappropriation of funds; Removal of
supervisor; Conditions requiring appointment of interim supervisor.
If the Supervisor of General Assistance is a defaulter and in arrears
with the governmental unit, or has misused, misappropriated, or
converted to his own use or the use of any other person any of the funds
of the unit, or is guilty of any other misconduct in office, the
governing body of the governmental unit, and in the case of a township,
the board of town trustees, may remove him as Supervisor of General
Assistance and appoint a suitable person to be the supervisor therein;
provided, that for a township containing 4,000 inhabitants or more, upon
written request of the township supervisors, the board of town trustees
may appoint a Supervisor of General Assistance who is a resident of such
township, and fix his compensation and term of office, which shall not
exceed the term of the board.
If, as provided in Section 12-21.18, the Illinois Department has
ordered the withholding of State funds for failure of the governmental
unit to comply with the Department's rules and regulations, the
governing body of the governmental unit, and in the case of a township,
the board of town trustees, upon written order of the Illinois
Department shall appoint an Interim Supervisor of General Assistance,
acceptable to the Illinois Department, to serve as Supervisor of General
Assistance for the governmental unit until such time as the policies and
procedures of the unit are determined by the Department to be in
compliance with its rules. If, after a reasonable time as determined by
the Illinois Department, the governmental unit or agency to which such
order is directed fails to make an appointment, or appoints a person who
is not acceptable to the Illinois Department, the Public Aid Committee,
established under Section 11-8, of the county in which the governmental
unit is located, upon written order of the Illinois Department, shall
appoint an Interim Supervisor, which appointment shall be subject to the
approval of the Illinois Department.
The appointing authority shall fix the compensation of the Interim
Supervisor of General Assistance, subject to approval of the Illinois
Department, which shall be payable from the general assistance fund of
the local governmental unit.
An Interim Supervisor of General Assistance may be removed and
another person appointed in his place in the same manner and for the
same reasons as in the case of an initial appointment of an Interim
Supervisor.
The Illinois Department shall not order the appointment of an Interim
Supervisor of General Assistance if the local governmental unit takes
such action as the Department considers to have established satisfactory
compliance with its rules, and a reasonable time, to be determined by
the Department, shall be allowed the governmental unit to establish such
compliance.
If an Interim Supervisor of General Assistance has been appointed, he
shall exercise all the powers of that office in respect to the
administration of general assistance, and shall have the sole authority
to disburse State and local funds available for this purpose. If the
governmental unit thereafter takes such action to assure the Department
that it will comply with the Department's rules, the service of the
Interim Supervisor shall be terminated.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-21.11) (from Ch. 23, par. 12-21.11)
Sec. 12-21.11.
Bonds.
Every Supervisor of General Assistance, including an Interim Supervisor
of General Assistance appointed as provided in Section 12-21.10, shall
execute to the governmental unit which he serves an official bond in a
penal sum and with sureties to be fixed and approved by the governing body
thereof, and, in the case of a township, as fixed and approved by the board
of town trustees, conditioned for the faithful discharge of his duties and
the due application of all funds and property which shall come to his hands
as such Supervisor. If the local governmental unit receives State funds in
accordance with the provisions of this Code, the amount and surety of the
bond shall be subject to the further approval of the Illinois Department.
(Source: P.A. 82-783.)
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(305 ILCS 5/12-21.12) (from Ch. 23, par. 12-21.12)
Sec. 12-21.12.
Actions against local governmental units - Intervention
of Attorney General. In any action against a local governmental unit to recover
expenditures alleged to be the responsibility of the governmental unit
under Article VI of this Code, the Supervisor of General
Assistance of such governmental unit shall notify the Illinois
Department of the filing of the action. If the governmental unit was a
recipient of State funds for public aid purposes during all or part of
the period of the expenditures for which the action is brought, or if,
as a result of the action, the governmental unit may qualify for and
request State funds, the Attorney General shall be permitted to
intervene and participate in the action in order to protect the State's
interest therein.
(Source: P.A. 81-1085.)
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(305 ILCS 5/12-21.13) (from Ch. 23, par. 12-21.13)
Sec. 12-21.13.
Local funds required to qualify for state aid.
To qualify
for State funds to supplement local funds for public aid purposes, a local
governmental unit shall, except as hereinafter provided, levy within the
time that such levy is authorized to be made a tax of an amount which, when
added to the unobligated balance available for such purposes at the close
of the fiscal year preceding the fiscal year for which the tax is levied
will equal .10% of the last known total equalized value of all taxable
property in the governmental unit.
In a county of less than 3 million population in which there is
created a County Veterans Assistance Commission, the county shall levy
for assistance to military veterans and their families, within the
time that such levy is authorized to be made, a tax of an amount which,
when added to the unobligated balance available for such purpose at the
close of the preceding fiscal year will equal .02% of the last known
assessed value of the taxable property in the county, or which will
equal .03% of such assessed value if such higher amount is authorized by
the electors of the county, as provided in Section 5-2006 of the Counties
Code.
If, however, at the latest date in the year on which the aforesaid
taxes are authorized to be levied there is in the unobligated balance of
the local governmental unit an amount equal to .10%, or .02% in the case
of Veterans' Assistance, of the last known total equalized value of all
taxable property in the governmental unit, then no tax need be levied in
that year in order for the local governmental unit to qualify for State
funds.
In determining the amount of the unobligated balance which is to be
applied in producing the required levy for receipt of State funds, or
which is to be applied in determining whether a tax levy is required,
there shall be deducted from the gross unobligated balance of funds
available at the close of the preceding fiscal year the total amount of
State funds allocated to the governmental unit during that year and the
total amount of any monies transferred to a township's general town fund
under Section 235-20 of the Township Code
during that year, and
only the remainder shall be considered in determining the amount of the
deficiency needed to produce an amount equal to the qualifying levy for
the current year.
(Source: P.A. 87-796; 88-670, eff. 12-2-94.)
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(305 ILCS 5/12-21.14) (from Ch. 23, par. 12-21.14)
Sec. 12-21.14.
Requirements; review by Illinois
Department; allocations. The County Board of each county or a duly
appointed committee thereof, or any other county agency designated by
the County Board, shall by the last day of each month submit to
the Illinois Department an itemized statement showing, for all local
governmental units therein except a city, village or incorporated town
of more than 500,000 population, assistance
furnished in the county under Article VI of this Code during the previous
month and the expenses for the administration thereof, and the actual
revenues available through taxation by the
local governmental
units. If the Illinois
Department has reason to believe that the amounts submitted by any
county are excessive, it may require appropriate officials of the county
to appear before it and substantiate the amounts to the satisfaction
of the Department.
The Illinois Department shall review these amounts and shall
determine and allocate to the several counties the amounts necessary to
supplement local funds actually available for public aid purposes. There
shall be a yearly reconciliation of amounts allocated to the local
governmental units by the Illinois Department to supplement local
funds.
If, because of circumstances beyond the local governmental unit's
control, such as a sudden caseload increase or an unexpected increase in
the administrative expenses, a local governmental unit has insufficient
local funds actually available to furnish assistance or pay administrative
expenses, the Illinois Department shall provide a special allocation of
funds to the local governmental unit to meet the need. In calculating the
need for a special allocation, the Illinois Department shall take into
consideration the amount of funds legally available from the taxes levied
by the local governmental unit for public aid purposes and any available
unobligated balances.
If a local governmental unit has not received State funds for public
aid purposes for at least 84 consecutive months immediately prior to its
request for State funds, the Illinois Department shall not consider as a
legally available resource of the governmental unit public aid funds, or
the proceeds of public aid taxes and tax anticipation warrants which may
have been transferred or expended during such period for other purposes.
Except as hereinafter provided, State allocations shall be paid to
the County Treasurer for disbursement to local governmental units as
certified by the Illinois Department. Until January 1, 1974, moneys
allocated by the Illinois Department for General Assistance purposes in
a city, village or incorporated town of more than 500,000 population and
moneys received from the Treasurer of the municipality from taxes levied
for General Assistance purposes in the municipality and other moneys and
funds designated in Section 11-43-2 of the Illinois Municipal Code shall
be paid into the special fund established by the County Treasurer of the
county in which the municipality is located and retained for
disbursement by the Director of the County Department of Public Aid
serving as Supervisor of General Assistance for the municipality.
On January 1, 1974, or as soon thereafter as is feasible but not
later than January 1, 1975, the County Treasurer shall transfer to the
Special Purposes Trust Fund (now known as the DHS Special Purposes Trust Fund) established by Section 12-10 of this Code
all State and municipal moneys remaining in or due to the special fund
of the County Treasury. After December 31, 1973, but not later than June
30, 1979, State allocations and municipal funds for General Assistance
purposes in such a municipality, and other moneys and funds designated
by Section 11-43-2 of the Illinois Municipal Code, shall be paid into
the Special Purposes Trust Fund (now known as the DHS Special Purposes Trust Fund) and disbursed as provided in Section
12-10. State and municipal moneys paid into the Special Purposes Trust
Fund (now known as the DHS Special Purposes Trust Fund) under the foregoing provision shall be used exclusively for (1)
furnishing General Assistance within the municipality; (2) the payment
of administrative costs; and (3) the payment of warrants issued against
and in anticipation of taxes levied by the municipality for General
Assistance purposes, and the accrued interest thereon. After June 30,
1979, moneys and funds designated by Section 11-43-2 of the Illinois
Municipal Code, shall be paid into the General Revenue Fund as
reimbursement for appropriated funds disbursed.
(Source: P.A. 99-933, eff. 1-27-17.)
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(305 ILCS 5/12-21.16) (from Ch. 23, par. 12-21.16)
Sec. 12-21.16.
Administrative costs.
In any local governmental unit receiving State funds, moneys expended
for costs of administration, exclusive of any compensation paid to the
Supervisor of General Assistance from funds other than public aid funds,
shall not exceed amounts which have been submitted to and approved by the
Illinois Department.
If a local governmental unit is a participating municipality in the
Illinois Municipal Retirement Fund created by Article 7 of the "Illinois
Pension Code", its estimate of administrative expenses may include amounts
required as contributions by the governmental unit in behalf of its
employees engaged in the administration of public aid for retirement
annuity purposes for current service rendered by such employees on and
after July 1, 1953, provided the governmental unit has levied a tax at a
rate not less than one-half the maximum rate authorized under Section 7-171
of the aforesaid Article.
Contributions for retirement annuity purposes of
employees of the County Department engaged in administration of General
Assistance for such a municipality shall be met from funds appropriated for
the State contribution to the State Employees Retirement System under
Article 14 of the "Illinois Pension Code".
The contributions of a governmental unit for retirement annuity purposes
which are authorized to be included in estimates of administrative expenses
shall include Social Security contributions for which the unit is obligated
under the Illinois Municipal Retirement Fund created by Article 7 of the
Illinois Pension Code, or if the governmental unit is not a participating
municipality in that Fund, the Social Security contributions for which it
is obligated pursuant to an agreement executed under Article 21 of the
Illinois Pension Code. In like manner, if the retirement fund established
under Article 9 of the Illinois Pension Code becomes obligated for Social
Security employer contributions, the estimated expenses of the County
Department may include the Social Security contributions together with the
regular contributions for which the county is obligated.
A local governmental unit receiving State funds may include in its
estimate of administrative expenses obligations assumed by it for insurance
premiums or charges for group life or health insurance, or both, for
employees of the local governmental unit, for any such employees who retire
or who had retired on or after January 1, 1966, and for dependents
receiving an annuity as survivors of such employees or retired employees if
the governmental unit has so acted under Section 3 of "An Act defining the
powers and duties of local governmental agencies to pay premiums and costs
or portions thereof, and to withhold parts of employee and elected or
appointed official compensation to provide insurance or retirement benefits
for employees and appointed or elected officials", approved August 16,
1963, as amended, or has so acted in exercise of its powers as a home rule
unit. The amount included for this purpose in the estimate of
administrative expenses shall not exceed the comparable insurance premiums
or charges per employee, retiree, or survivor currently paid by the State
of Illinois for State employees under the "State Employees Group Insurance
Act of 1971".
(Source: P.A. 78-1297.)
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(305 ILCS 5/12-21.17) (from Ch. 23, par. 12-21.17)
Sec. 12-21.17.
Supervision by Illinois Department.
If a local governmental
unit receives State funds for public aid
purposes under Article VI its administration, including the use of local
resources, shall be subject to the supervision and the rules and
regulations of the Illinois Department. The Department shall also
supervise the setting of the local uniform budget standard and its
enforcement.
Such units and the officers thereof shall deliver to the Illinois
Department for examination and inspection all books, records, accounts,
and other documents which the Department requires.
(Source: P.A. 81-1085.)
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(305 ILCS 5/12-21.18) (from Ch. 23, par. 12-21.18)
Sec. 12-21.18.
Non-compliance with rules of the Illinois Department.
If a local governmental unit subject to the supervision of the Illinois
Department is, in the determination of the Department, refusing or failing
to comply with the Department's rules and regulations, the Illinois
Department shall give notice promptly by United States registered or
certified mail to the Supervisor of General Assistance or other proper
officer of such unit of the rules which are not being observed and give the
governmental unit or its designated representative an opportunity to appear
before it and substantiate its position in respect to the rule or rules at
issue.
If within 5 days after such notice, the local governmental unit
continues to refuse or fails to comply with the Department's rules, or
fails to avail itself of the opportunity offered for a hearing before the
Department, the Department shall instruct the County Treasurer of the
County in which the governmental unit is located to withhold the payment of
any further State funds until he receives notice from the Department to
release the funds.
The Illinois Department may suspend an order for the withholding of
funds (1) if the governmental unit takes such action as the Department
considers to have established satisfactory compliance with its rules or (2)
upon appointment of an Interim Supervisor of General Assistance, as
directed by the provisions of Section 12-21.10.
The provisions of the Administrative Review Law,
as amended, and the rules adopted pursuant thereto, shall apply to and
govern proceedings for the judicial review of final administrative
decisions of the Illinois Department under this Section. The term
"administrative decision" is defined as in Section 3-101 of the Code of Civil Procedure.
(Source: P.A. 82-783.)
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(305 ILCS 5/12-21.20) (from Ch. 23, par. 12-21.20)
Sec. 12-21.20.
Destruction of Obsolete Records.
Obsolete records, documents,
papers, and memoranda pertaining to
public aid under Article VI may be destroyed or otherwise
disposed of by local governmental units at any time subsequent to the
expiration of 5 years after the matters to which they relate have been
concluded.
(Source: P.A. 92-111, eff. 1-1-02.)
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(305 ILCS 5/12-21.21) Sec. 12-21.21. Federal waiver or State Plan amendment. The Department of Healthcare and Family Services and the Department of Human Services shall jointly submit the necessary application to the federal Centers for Medicare and Medicaid Services for a waiver or State Plan amendment to allow remote monitoring and support services as a waiver-reimbursable service for persons with intellectual and developmental disabilities. The application shall be submitted no later than January 1, 2021. No later than July 1, 2021, the Department of Human Services shall adopt rules to allow remote monitoring and support services at community-integrated living arrangements.
(Source: P.A. 101-649, eff. 7-7-20.) |
(305 ILCS 5/Art. XIII heading) ARTICLE XIII.
PURPOSE--REPEAL--SAVINGS
PROVISIONS--PARTIAL INVALIDITY--
EFFECTIVE DATE
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(305 ILCS 5/13-1) (from Ch. 23, par. 13-1)
Sec. 13-1.
Purpose.
It is the purpose of this Code to restate, simplify, eliminate
obsolescences and redundancies and reorganize into a more understandable
and usable form the provisions of the 1949 Code repealed hereby.
It is intended that this Code shall grant no lesser or greater rights or
impose any greater or lesser obligations upon applicants or recipients or
administrative agencies than exercised under such prior Code except as they
may be changed hereafter by specific amendment to this Code. All such
rights and obligations are preserved without change, and without loss or
impairment, precisely as if such Code had not been repealed.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/13-2) (from Ch. 23, par. 13-2)
Sec. 13-2.
Repeal.
The "Act to revise the public assistance laws of Illinois, to
consolidate and codify such laws, to prescribe the functions, powers, and
duties of governmental units, agencies, and persons thereunder, to provide
penalties for the violation thereof and to repeal certain Acts herein
named", approved August 4, 1949, as amended, referred to herein as the
1949 Code, is repealed.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/13-3) (from Ch. 23, par. 13-3)
Sec. 13-3.
Savings
provisions.
The repeal of the 1949 Code Act shall not affect or impair the
continuity of grants heretofore made to or in behalf of recipients pursuant
to said Code. Nor shall such repeal affect or impair any power or the
performance of any act or duty by any governmental unit, or officer, agency
or employee thereof, validly exercised, performed or done under said Code.
However, after the effective date of this Code all such recipients,
governmental units, agencies, officers and employees shall in all respects
be subject to and governed by the provisions of this Code.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/13-4) (from Ch. 23, par. 13-4)
Sec. 13-4.
Partial
invalidity.
Should any Section, subdivision, clause, phrase, or provision of this
Code to be unconstitutional or invalid for any reason whatsoever such
holdings shall not affect the validity of the remaining portions of this
Code.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/13-5) (from Ch. 23, par. 13-5)
Sec. 13-5.
Emergency-effective date.
Whereas many members of the General Assembly wish to offer bills
amending the law relating to public assistance at the current session of
the General Assembly and such bills should be drafted as amendments to this
Act and not to the 1949 Act, therefore an emergency exists and this Act
shall take effect upon its becoming a law.
(Source: Laws 1967, p. 122.)
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(305 ILCS 5/Art. XIV heading) ARTICLE XIV. HOSPITAL SERVICES TRUST FUND
(Source: P.A. 103-154, eff. 6-30-23.) |
(305 ILCS 5/14-1) (from Ch. 23, par. 14-1)
Sec. 14-1. Definitions. As used in this Article, unless the
context requires otherwise:
"Hospital" means any institution, place, building, or agency, public
or private, whether organized for profit or not-for-profit, which is
located in the State and is subject to licensure by the Illinois
Department of Public Health under the Hospital Licensing Act or any
institution, place, building, or agency, public or private, whether organized
for profit or not-for-profit, which meets all comparable conditions and
requirements of the Hospital Licensing Act in effect for the state in
which it is located, and is required to submit cost reports to the
Illinois Department under Title 89, Part 148, of the Illinois
Administrative Code, but shall not include the University of Illinois
Hospital as defined in
the University of Illinois Hospital Act or a county hospital in a county
of over 3 million population.
(Source: P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-2) (from Ch. 23, par. 14-2)
Sec. 14-2.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-3) (from Ch. 23, par. 14-3)
Sec. 14-3.
(Repealed).
(Source: P.A. 87-861. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-4) (from Ch. 23, par. 14-4)
Sec. 14-4.
(Repealed).
(Source: P.A. 87-13. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-5) (from Ch. 23, par. 14-5)
Sec. 14-5.
(Repealed).
(Source: P.A. 87-13. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-6) (from Ch. 23, par. 14-6)
Sec. 14-6.
(Repealed).
(Source: P.A. 87-13. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-7) (from Ch. 23, par. 14-7)
Sec. 14-7.
(Repealed).
(Source: P.A. 87-13. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-8) (from Ch. 23, par. 14-8)
Sec. 14-8. Disbursements to Hospitals.
(a) For inpatient hospital services rendered on and after September 1,
1991, the Illinois Department shall reimburse
hospitals for inpatient services at an inpatient payment rate calculated for
each hospital based upon the Medicare Prospective Payment System as set forth
in Sections 1886(b), (d), (g), and (h) of the federal Social Security Act, and
the regulations, policies, and procedures promulgated thereunder, except as
modified by this Section. Payment rates for inpatient hospital services
rendered on or after September 1, 1991 and on or before September 30, 1992
shall be calculated using the Medicare Prospective Payment rates in effect on
September 1, 1991. Payment rates for inpatient hospital services rendered on
or after October 1, 1992 and on or before March 31, 1994 shall be calculated
using the Medicare Prospective Payment rates in effect on September 1, 1992.
Payment rates for inpatient hospital services rendered on or after April 1,
1994 shall be calculated using the Medicare Prospective Payment rates
(including the Medicare grouping methodology and weighting factors as adjusted
pursuant to paragraph (1) of this subsection) in effect 90 days prior to the
date of admission. For services rendered on or after July 1, 1995, the
reimbursement methodology implemented under this subsection shall not include
those costs referred to in Sections 1886(d)(5)(B) and 1886(h) of the Social
Security Act. The additional payment amounts required under Section
1886(d)(5)(F) of the Social Security Act, for hospitals serving a
disproportionate share of low-income or indigent patients, are not required
under this Section. For hospital inpatient services rendered on or after July
1, 1995 and on or before June 30, 2014, the Illinois Department shall
reimburse hospitals using the relative weighting factors and the base payment
rates calculated for each hospital that were in effect on June 30, 1995, less
the portion of such rates attributed by the Illinois Department to the cost of
medical education.
(1) The weighting factors established under Section | ||
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(2) The Illinois Department shall define by rule | ||
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(3) (Blank).
(4) Notwithstanding any other provision of this | ||
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(5) In addition to any payments made under this | ||
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(b) (Blank).
(b-5) Excepting county providers as defined in Article XV of this Code,
hospitals licensed under the University of Illinois Hospital Act, and
facilities operated by the Illinois Department of Mental Health and
Developmental Disabilities (or its successor, the Department of Human
Services), for outpatient services rendered on or after July 1, 1995
and before July 1, 1998 the Illinois Department shall reimburse
children's hospitals, as defined in the Illinois Administrative Code
Section 149.50(c)(3), at the rates in effect on June 30, 1995, less that
portion of such rates attributed by the Illinois Department to the outpatient
indigent volume adjustment and shall reimburse all other hospitals at the rates
in effect on June 30, 1995, less the portions of such rates attributed by the
Illinois Department to the cost of medical education and attributed by the
Illinois Department to the outpatient indigent volume adjustment. For
outpatient services provided on or after July 1, 1998 and on or before June 30, 2014, reimbursement rates
shall be established by rule.
(c) In addition to any other payments under this Code, the Illinois
Department shall develop a hospital disproportionate share reimbursement
methodology that, effective July 1, 1991, through September 30, 1992,
shall reimburse hospitals sufficiently to expend the fee monies described
in subsection (b) of Section 14-3 of this Code and the federal matching
funds received by the Illinois Department as a result of expenditures made
by the Illinois Department as required by this subsection (c) and Section
14-2 that are attributable to fee monies deposited in the Fund, less
amounts applied to adjustment payments under Section 5-5.02.
(d) Critical Care Access Payments.
(1) In addition to any other payments made under this | ||
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(2) "Critical Care Access Hospitals" includes, but is | ||
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(A) Hospitals located outside of a metropolitan | ||
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(B) Hospitals that are designated as Level I | ||
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(C) Hospitals located outside of a metropolitan | ||
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(e) Inpatient high volume adjustment. For hospital inpatient services,
effective with rate periods beginning on or after October 1, 1993, in
addition to rates paid for inpatient services by the Illinois Department, the
Illinois Department shall make adjustment payments for inpatient services
furnished by Medicaid high volume hospitals. The Illinois Department shall
establish by rule criteria for qualifying as a Medicaid high volume hospital
and shall establish by rule a reimbursement methodology for calculating these
adjustment payments to Medicaid high volume hospitals. No adjustment payment
shall be made under this subsection for services rendered on or after July 1,
1995.
(f) The Illinois Department shall modify its current rules governing
adjustment payments for targeted access, critical care access, and
uncompensated care to classify those adjustment payments as not being payments
to disproportionate share hospitals under Title XIX of the federal Social
Security Act. Rules adopted under this subsection shall not be effective with
respect to services rendered on or after July 1, 1995. The Illinois Department
has no obligation to adopt or implement any rules or make any payments under
this subsection for services rendered on or after July 1, 1995.
(f-5) The State recognizes that adjustment payments to hospitals providing
certain services or incurring certain costs may be necessary to assure that
recipients of medical assistance have adequate access to necessary medical
services. These adjustments include payments for teaching costs and
uncompensated care, trauma center payments, rehabilitation hospital payments,
perinatal center payments, obstetrical care payments, targeted access payments,
Medicaid high volume payments, and outpatient indigent volume payments. On or
before April 1, 1995, the Illinois Department shall issue recommendations
regarding (i) reimbursement mechanisms or adjustment payments to reflect these
costs and services, including methods by which the payments may be calculated
and the method by which the payments may be financed, and (ii) reimbursement
mechanisms or adjustment payments to reflect costs and services of federally
qualified health centers with respect to recipients of medical assistance.
(g) If one or more hospitals file suit in any court challenging any part of
this Article XIV, payments to hospitals under this Article XIV shall be made
only to the extent that sufficient monies are available in the Fund and only to
the extent that any monies in the Fund are not prohibited from disbursement
under any order of the court.
(h) Payments under the disbursement methodology described in this Section
are subject to approval by the federal government in an appropriate State plan
amendment.
(i) The Illinois Department may by rule establish criteria for and develop
methodologies for adjustment payments to hospitals participating under this
Article.
(j) Hospital Residing Long Term Care Services. In addition to any other
payments made under this Code, the Illinois Department may by rule establish
criteria and develop methodologies for payments to hospitals for Hospital
Residing Long Term Care Services.
(k) Critical Access Hospital outpatient payments. In addition to any other payments authorized under this Code, the Illinois Department shall reimburse critical access hospitals, as designated by the Illinois Department of Public Health in accordance with 42 CFR 485, Subpart F, for outpatient services at an amount that is no less than the cost of providing such services, based on Medicare cost principles. Payments under this subsection shall be subject to appropriation. (l) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14.)
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(305 ILCS 5/14-9) (from Ch. 23, par. 14-9)
Sec. 14-9.
(Repealed).
(Source: P.A. 87-13. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-10) (from Ch. 23, par. 14-10)
Sec. 14-10.
(Repealed).
(Source: P.A. 87-861. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/14-11) Sec. 14-11. Hospital payment reform. (a) The Department may, by rule, implement the All Patient Refined Diagnosis Related Groups (APR-DRG) payment system for inpatient services provided on or after July 1, 2013, in a manner consistent with the actions authorized in this Section. (b) On or before October 1, 2012 and through June 30, 2013, the Department shall begin testing the APR-DRG system. During the testing period the Department shall process and price inpatient services using the APR-DRG system; however, actual payments for those inpatient services shall be made using the current reimbursement system. During the testing period, the Department, in collaboration with the statewide representative of hospitals, shall provide information and technical assistance to hospitals to encourage and facilitate their transition to the APR-DRG system. (c) The Department may, by rule, implement the Enhanced Ambulatory Procedure Grouping (EAPG) system for outpatient services provided on or after January 1, 2014, in a manner consistent with the actions authorized in this Section. On or before January 1, 2013 and through December 31, 2013, the Department shall begin testing the EAPG system. During the testing period the Department shall process and price outpatient services using the EAPG system; however, actual payments for those outpatient services shall be made using the current reimbursement system. During the testing period, the Department, in collaboration with the statewide representative of hospitals, shall provide information and technical assistance to hospitals to encourage and facilitate their transition to the EAPG system. (d) The Department in consultation with the current hospital technical advisory group shall review the test claims for inpatient and outpatient services at least monthly, including the estimated impact on hospitals, and, in developing the rules, policies, and procedures to implement the new payment systems, shall consider at least the following issues: (1) The use of national relative weights provided by | ||
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(2) An updated outlier payment methodology based on | ||
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(3) The use of policy adjusters to enhance payments | ||
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(4) Reimbursement for inpatient specialty services | ||
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(5) The creation of one or more transition funding | ||
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(6) Whether, beginning July 1, 2014, some of the | ||
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(e) The Department shall provide the association representing the majority of hospitals in Illinois, as the statewide representative of the hospital community, with a monthly file of claims adjudicated under the test system for the purpose of review and analysis as part of the collaboration between the State and the hospital community. The file shall consist of a de-identified extract compliant with the Health Insurance Portability and Accountability Act (HIPAA). (f) The current hospital technical advisory group shall make recommendations for changes during the testing period and recommendations for changes prior to the effective dates of the new payment systems. The Department shall draft administrative rules to implement the new payment systems and provide them to the technical advisory group at least 90 days prior to the proposed effective dates of the new payment systems. (g) The payments to hospitals financed by the current hospital assessment, authorized under Article V-A of this Code, are scheduled to sunset on June 30, 2014. The continuation of or revisions to the hospital assessment program shall take into consideration the impact on hospitals and access to care as a result of the changes to the hospital payment system. (h) Beginning July 1, 2014, the Department may transition current General Revenue funded supplemental payments into the claims based system over a period of no less than 2 years from the implementation date of the new payment systems and no more than 4 years from the implementation date of the new payment systems, provided however that the Department may adopt, by rule, supplemental payments to help ensure access to care in a geographic area or to help ensure access to specialty services. For any supplemental payments that are adopted that are based on historic data, the data shall be no older than 3 years and the supplemental payment shall be effective for no longer than 2 years before requiring the data to be updated. (i) Any payments authorized under 89 Illinois Administrative Code 148 set to expire in State fiscal year 2012 and that were paid out to hospitals in State fiscal year 2012 shall remain in effect as long as the assessment imposed by Section 5A-2 is in effect. (j) Subsections (a) and (c) of this Section shall remain operative unless the Auditor General has reported that: (i) the Department has not undertaken the required actions listed in the report required by subsection (a) of Section 2-20 of the Illinois State Auditing Act; or (ii) the Department has failed to comply with the reporting requirements of Section 2-20 of the Illinois State Auditing Act. (k) Subsections (a) and (c) of this Section shall not be operative until final federal approval by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and implementation of all of the payments and assessments in Article V-A in its form as of the effective date of this amendatory Act of the 97th General Assembly or as it may be amended.
(Source: P.A. 97-689, eff. 6-14-12.) |
(305 ILCS 5/14-12) Sec. 14-12. Hospital rate reform payment system. The hospital payment system pursuant to Section 14-11 of this Article shall be as follows: (a) Inpatient hospital services. Effective for discharges on and after July 1, 2014, reimbursement for inpatient general acute care services shall utilize the All Patient Refined Diagnosis Related Grouping (APR-DRG) software, version 30, distributed by 3MTM Health Information System. (1) The Department shall establish Medicaid weighting | ||
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(2) The Department shall establish a | ||
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(3) In addition to the statewide-standardized amount, | ||
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(4) The Department shall develop add-on payments to | ||
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(5) The Department shall define those hospitals or | ||
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(6) Beginning July 1, 2014 and ending on December 31, | ||
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(7) Beginning July 1, 2014, in addition to the | ||
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(7.5) (Blank). (8) Beginning July 1, 2018, in addition to the | ||
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(9) Beginning July 1, 2018, in addition to the | ||
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(10) Beginning July 1, 2018, the | ||
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(11) Beginning July 1, 2018, the reimbursement for | ||
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(b) Outpatient hospital services. Effective for dates of service on and after July 1, 2014, reimbursement for outpatient services shall utilize the Enhanced Ambulatory Procedure Grouping (EAPG) software, version 3.7 distributed by 3MTM Health Information System. (1) The Department shall establish Medicaid weighting | ||
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(2) The Department shall establish service specific | ||
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(A) The initial statewide standardized amounts, | ||
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(B) The Department shall establish adjustments to | ||
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(3) In addition to the statewide-standardized | ||
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(4) Beginning July 1, 2018, in addition to the | ||
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(5) Beginning July 1, 2018, the | ||
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(6) Effective for dates of service on or after July | ||
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(7) Effective for dates of service on or after March | ||
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(1) Any recalculation to the | ||
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(2) It is the intent of the General Assembly that | ||
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(8) The Department shall ensure that all necessary | ||
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(9) Within 60 days after federal approval of the | ||
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(b-5) Notwithstanding any other provision of this Section, beginning with dates of service on and after January 1, 2023, any general acute care hospital with more than 500 outpatient psychiatric Medicaid services to persons under 19 years of age in any calendar year shall be paid the outpatient add-on payment of no less than $113. (c) In consultation with the hospital community, the Department is authorized to replace 89 Ill. Adm. Code 152.150 as published in 38 Ill. Reg. 4980 through 4986 within 12 months of June 16, 2014 (the effective date of Public Act 98-651). If the Department does not replace these rules within 12 months of June 16, 2014 (the effective date of Public Act 98-651), the rules in effect for 152.150 as published in 38 Ill. Reg. 4980 through 4986 shall remain in effect until modified by rule by the Department. Nothing in this subsection shall be construed to mandate that the Department file a replacement rule. (d) Transition period.
There shall be a transition period to the reimbursement systems authorized under this Section that shall begin on the effective date of these systems and continue until June 30, 2018, unless extended by rule by the Department. To help provide an orderly and predictable transition to the new reimbursement systems and to preserve and enhance access to the hospital services during this transition, the Department shall allocate a transitional hospital access pool of at least $290,000,000 annually so that transitional hospital access payments are made to hospitals. (1) After the transition period, the Department may | ||
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(2) After the transition period, if the Department | ||
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(d-5) Hospital and health care transformation program. The Department shall develop a hospital and health care transformation program to provide financial assistance to hospitals in transforming their services and care models to better align with the needs of the communities they serve. The payments authorized in this Section shall be subject to approval by the federal government. (1) Phase 1. In State fiscal years 2019 through | ||
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(A) If the hospital's Rate Year 2017 Medicaid | ||
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(B) If the hospital's Rate Year 2017 Medicaid | ||
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(C) If the hospital's Rate Year 2017 Medicaid | ||
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(2) Phase 2. (A) The funding amount from phase one shall be | ||
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(B) Because there are communities in Illinois | ||
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The Department shall convene, within 30 days | ||
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(C) As provided in paragraph (9) of Section 3 of | ||
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(D) As provided in subsection (a-20) of Section | ||
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(E) Criteria for proposals. To be eligible for | ||
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(i) the proposal shall be designed based on | ||
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(ii) the proposal shall be a collaboration | ||
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(iii) the proposal shall be specifically | ||
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(iv) the proposal shall have specific | ||
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(v) the proposal shall include a commitment | ||
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(vi) the proposal shall specifically increase | ||
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(F) Entities eligible to be funded. (i) Proposals for funding should come from | ||
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(ii) The Department shall prioritize | ||
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(iii) The Department should target the | ||
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(iv) The Department may allocate up to | ||
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(v) The Department shall take steps to ensure | ||
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(G) Process for submitting and approving projects | ||
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(i) A detailed description of how the project | ||
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(ii) A detailed description of the racial and | ||
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(iii) A complete budget, including an overall | ||
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(iv) A description of any new entities formed | ||
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(v) A timeline showing the evolution of sites | ||
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(vi) Clear milestones indicating progress | ||
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(vii) A clear statement of the level of | ||
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(viii) If the community study utilized is not | ||
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(ix) A description of the process used in | ||
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(x) Documentation of a community input | ||
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(xi) Verifiable project milestones and | ||
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(xii) Data on the number of existing | ||
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(xiii) If a new entity is created by the | ||
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(xiv) An explanation of how the proposal will | ||
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(xv) An explanation of how the proposal is | ||
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(H) The Department shall evaluate proposals for | ||
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In reviewing the proposals, the Department shall | ||
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(3) (Blank). (4) Hospital Transformation Review Committee. There | ||
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(e) Beginning 36 months after initial implementation, the Department shall update the reimbursement components in subsections (a) and (b), including standardized amounts and weighting factors, and at least once every 4 years and no more frequently than annually thereafter. The Department shall publish these updates on its website no later than 30 calendar days prior to their effective date. (f) Continuation of supplemental payments. Any supplemental payments authorized under Illinois Administrative Code 148 effective January 1, 2014 and that continue during the period of July 1, 2014 through December 31, 2014 shall remain in effect as long as the assessment imposed by Section 5A-2 that is in effect on December 31, 2017 remains in effect. (g) Notwithstanding subsections (a) through (f) of this Section and notwithstanding the changes authorized under Section 5-5b.1, any updates to the system shall not result in any diminishment of the overall effective rates of reimbursement as of the implementation date of the new system (July 1, 2014). These updates shall not preclude variations in any individual component of the system or hospital rate variations. Nothing in this Section shall prohibit the Department from increasing the rates of reimbursement or developing payments to ensure access to hospital services. Nothing in this Section shall be construed to guarantee a minimum amount of spending in the aggregate or per hospital as spending may be impacted by factors, including, but not limited to, the number of individuals in the medical assistance program and the severity of illness of the individuals. (h) The Department shall have the authority to modify by rulemaking any changes to the rates or methodologies in this Section as required by the federal government to obtain federal financial participation for expenditures made under this Section. (i) Except for subsections (g) and (h) of this Section, the Department shall, pursuant to subsection (c) of Section 5-40 of the Illinois Administrative Procedure Act, provide for presentation at the June 2014 hearing of the Joint Committee on Administrative Rules (JCAR) additional written notice to JCAR of the following rules in order to commence the second notice period for the following rules: rules published in the Illinois Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559 (Medical Payment), 4628 (Specialized Health Care Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic Related Grouping (DRG) Prospective Payment System (PPS)), and 4977 (Hospital Reimbursement Changes), and published in the Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499 (Specialized Health Care Delivery Systems) and 6505 (Hospital Services).
(j) Out-of-state hospitals. Beginning July 1, 2018, for purposes of determining for State fiscal years 2019 and 2020 and subsequent fiscal years the hospitals eligible for the payments authorized under subsections (a) and (b) of this Section, the Department shall include out-of-state hospitals that are designated a Level I pediatric trauma center or a Level I trauma center by the Department of Public Health as of December 1, 2017. (k) The Department shall notify each hospital and managed care organization, in writing, of the impact of the updates under this Section at least 30 calendar days prior to their effective date. (l) This Section is subject to Section 14-12.5. (Source: P.A. 102-682, eff. 12-10-21; 102-1037, eff. 6-2-22; 103-102, eff. 6-16-23; 103-154, eff. 6-30-23.) |
(305 ILCS 5/14-12.5) Sec. 14-12.5. Hospital rate updates. (a) Notwithstanding any other provision of this Code, the hospital rates of reimbursement authorized under Sections 5-5.05, 14-12, and 14-13 of this Code shall be adjusted in accordance with the provisions of this Section. (b) Notwithstanding any other provision of this Code, effective for dates of service on and after January 1, 2024, subject to federal approval, hospital reimbursement rates shall be revised as follows: (1) For inpatient general acute care services, the | ||
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(2) For inpatient psychiatric services: (A) For safety-net hospitals, the hospital | ||
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(B) For all general acute care hospitals that are | ||
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(C) For all psychiatric specialty hospitals, the | ||
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(3) For inpatient rehabilitative services, all | ||
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(4) The statewide-standardized amount for outpatient | ||
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(5) The statewide-standardized amount for outpatient | ||
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(6) The statewide-standardized amount for outpatient | ||
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(7) The per diem rate in effect January 1, 2023, as | ||
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(8) For services provided on and after January 1, | ||
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(A) For Psychiatric days of care, the Department | ||
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(B) If the add-on adjustment is added to the | ||
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(C) The add-on adjustment shall not be considered | ||
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(9) For services provided on and after July 1, 2024, | ||
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(A) if the safety-net hospital's Medicaid | ||
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(B) if the safety-net hospital's Medicaid | ||
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(C) if the safety-net hospital's Medicaid | ||
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(D) if the safety-net hospital's Medicaid | ||
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Qualification for the safety-net hospital health care | ||
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Rates described in subparagraphs (A) through (C) | ||
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The add-on adjustment under this paragraph shall not | ||
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(10) For services provided on and after July 1, 2024, | ||
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(c) The Department shall take all actions necessary to ensure the changes authorized in Public Act 103-102 and this amendatory Act of the 103rd General Assembly are in effect for dates of service on and after the effective date of the changes made to this Section by this amendatory Act of the 103rd General Assembly, including publishing all appropriate public notices, applying for federal approval of amendments to the Illinois Title XIX State Plan, and adopting administrative rules if necessary. (d) The Department of Healthcare and Family Services may adopt rules necessary to implement the changes made by Public Act 103-102 and this amendatory Act of the 103rd General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act. The 24-month limitation on the adoption of emergency rules does not apply to rules adopted under this Section. The General Assembly finds that the adoption of rules to implement the changes made by Public Act 103-102 and this amendatory Act of the 103rd General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare. (e) The Department shall ensure that all necessary adjustments to the managed care organization capitation base rates necessitated by the adjustments in this Section are completed, published, and applied in accordance with Section 5-30.8 of this Code 90 days prior to the implementation date of the changes required under Public Act 103-102 and this amendatory Act of the 103rd General Assembly. (f) The Department shall publish updated rate sheets or add-on payment amounts, as applicable, for all hospitals 30 days prior to the effective date of the rate increase, or within 30 days after federal approval by the Centers for Medicare and Medicaid Services, whichever is later. (Source: P.A. 103-102, eff. 6-16-23; 103-593, eff. 6-7-24.) |
(305 ILCS 5/14-12.7) Sec. 14-12.7. Public critical access hospital stabilization program. (a) In order to address the growing challenges of providing stable access to healthcare in rural Illinois, by October 1, 2023, the Department shall adopt rules to implement for dates of service on and after January 1, 2024, subject to federal approval, a program to provide at least $3,500,000 in annual financial support to public, critical access hospitals in Illinois, for the delivery of perinatal and obstetrical or gynecological services, behavioral healthcare services, including substance use disorder services, telehealth services, and other specialty services. (b) The funding allocation methodology shall provide added consideration to the services provided by qualifying hospitals designated by the Department of Public Health as a perinatal center. (c) Public critical access hospitals qualifying under this Section shall not be eligible for payment under subsection (o) of Section 5A-12.7 of this Code. (d) As used in this Section, "public critical access hospital" means a hospital designated by the Department of Public Health as a critical access hospital and that is owned or operated by an Illinois Government body or municipality.
(Source: P.A. 103-102, eff. 6-16-23.) |
(305 ILCS 5/14-13) Sec. 14-13. Reimbursement for inpatient stays extended beyond medical necessity. (a) By October 1, 2019, the Department shall by rule implement a methodology effective for dates of service July 1, 2019 and later to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department or the managed care organization in which a recipient is enrolled or the hospital discharge planner to find an appropriate placement after discharge from the hospital. The Department shall evaluate the effectiveness of the current reimbursement rate for inpatient hospital stays beyond medical necessity. (b) The methodology shall provide reasonable compensation for the services provided attributable to the days of the extended stay for which the prevailing rate methodology provides no reimbursement. The Department may use a day outlier program to satisfy this requirement. The reimbursement rate shall be set at a level so as not to act as an incentive to avoid transfer to the appropriate level of care needed or placement, after discharge. (c) The Department shall require managed care organizations to adopt this methodology or an alternative methodology that pays at least as much as the Department's adopted methodology unless otherwise mutually agreed upon contractual language is developed by the provider and the managed care organization for a risk-based or innovative payment methodology. (d) Days beyond medical necessity shall not be eligible for per diem add-on payments under the Medicaid High Volume Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA) programs. (e) For services covered by the fee-for-service program, reimbursement under this Section shall only be made for days beyond medical necessity that occur after the hospital has notified the Department of the need for post-discharge placement. For services covered by a managed care organization, hospitals shall notify the appropriate managed care organization of an admission within 24 hours of admission. For every 24-hour period beyond the initial 24 hours after admission that the hospital fails to notify the managed care organization of the admission, reimbursement under this subsection shall be reduced by one day. (f) The Department of Children and Family Services shall pay for all inpatient stays beginning on the 3rd day a child is in the hospital beyond medical necessity, and the parent or caregiver has denied the child access to the home and has refused or failed to make provisions for another living arrangement for the child or the child's discharge is being delayed due to a pending inquiry or investigation by the Department of Children and Family Services. (Source: P.A. 102-4, eff. 4-27-21; 103-593, eff. 6-7-24.) |
(305 ILCS 5/14-14) Sec. 14-14. Increasing access to primary care in hospitals. The Department of Healthcare and Family Services shall develop a program to facilitate coordination between Federally Qualified Health Centers (FQHCs) and safety net hospitals, with the goal of increasing care coordination, managing chronic diseases, and addressing the social determinants of health on or before December 31, 2021. Coordination between FQHCs and safety hospitals may include, but is not limited to, embedding FQHC staff in hospitals, utilizing health information technology for care coordination, and enabling FQHCs to connect hospital patients to community-based resources when needed to provide whole-person care. In addition, the Department shall develop a payment methodology to allow FQHCs to provide care coordination services, including, but not limited to, chronic disease management and behavioral health services. The Department of Healthcare and Family Services shall develop a payment methodology to allow for FQHC care coordination services by no later than December 31, 2021.
(Source: P.A. 102-4, eff. 4-27-21.) |
(305 ILCS 5/Art. XV heading) ARTICLE XV.
COUNTY PROVIDER TRUST FUND
(Source: P.A. 103-154, eff. 6-30-23.) |
(305 ILCS 5/15-1) (from Ch. 23, par. 15-1)
Sec. 15-1. Definitions. As used in this Article, unless the context
requires otherwise:
(a) (Blank).
(a-5) "County provider" means a health care provider that is, or is
operated by, a county with a population greater than 3,000,000.
(b) "Fund" means the County Provider Trust Fund.
(c) "Hospital" or "County hospital" means a hospital, as defined in Section
14-1 of this Code, which is a county hospital located in a county of over
3,000,000 population.
(Source: P.A. 97-687, eff. 6-14-12; 97-689, eff. 6-14-12.)
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(305 ILCS 5/15-2) (from Ch. 23, par. 15-2)
Sec. 15-2. County Provider Trust Fund.
(a) There is created in the State Treasury the County Provider
Trust Fund. Interest earned by the Fund shall be credited to the Fund.
The Fund shall not be used to replace any funds appropriated to the
Medicaid program by the General Assembly.
(b) The Fund is created solely for the purposes of receiving, investing,
and distributing monies in accordance with this Article XV. The Fund shall
consist of:
(1) All monies collected or received by the Illinois | ||
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(2) All federal financial participation monies | ||
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(3) All federal moneys received by the Illinois | ||
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(4) All other monies received by the Fund from any | ||
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(c) Disbursements from the Fund shall be by warrants drawn by the State
Comptroller upon receipt of vouchers duly executed and certified by the
Illinois Department and shall be made only:
(1) For hospital inpatient care, hospital outpatient | ||
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(1.5) For services provided or purchased by county | ||
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(2) For the reimbursement of administrative expenses | ||
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(3) For the reimbursement of monies received by the | ||
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(4) For the payment of administrative expenses | ||
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(5) For the payment of any amounts that are | ||
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(6) For hospital inpatient care, hospital outpatient | ||
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(7) For medical care and related services provided | ||
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(Source: P.A. 97-687, eff. 6-14-12.)
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(305 ILCS 5/15-3) (from Ch. 23, par. 15-3)
Sec. 15-3. Intergovernmental Transfers.
(a) Each qualifying county shall make an annual intergovernmental transfer
to the Illinois Department in an amount equal to the difference
between the total payments made by the Illinois Department pursuant to subsection (a) of Section 15-5 of this Code
and the total federal financial participation monies received by the fund in
each fiscal year ending June 30.
(b) The payment schedule for the intergovernmental transfer made
hereunder shall be established by intergovernmental agreement between the
Illinois Department and the applicable county, which agreement shall at
a minimum provide:
(1) For periodic payments no less frequently than | ||
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(2) (Blank.)
(3) For calculation of the intergovernmental transfer | ||
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(4) For an intergovernmental transfer methodology | ||
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(Source: P.A. 95-859, eff. 8-19-08.)
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(305 ILCS 5/15-4) (from Ch. 23, par. 15-4)
Sec. 15-4.
Contractual assumption of certain expenses.
Hospitals may,
at their election, by written agreement between the counties owning and
operating the hospitals and the Illinois Department, assume specified
expenses of the operation of the Illinois Department associated with the
determination of eligibility, direct payment of which expenses by the
Illinois Department would qualify as public funds expended by the Illinois
Department for the Illinois Medical Assistance Program or other health
care programs administered by the Illinois Department. The Illinois
Department shall open an adequately staffed special on-site office or
offices at facilities designated by the county for the purpose of assisting
the county in ensuring that all eligible individuals are enrolled in the
Illinois Medical Assistance Program. Each such agreement, executed in
accordance with Section 3 of the Intergovernmental Cooperation Act, shall
describe the operational expenses to be assumed in sufficient detail to
permit the Illinois Department to certify upon such written obligation or
performance thereunder that the hospital's compliance with the terms of the
agreement will amount to the commitment of public funds eligible for the
federal financial participation or other federal funding called for in
Title XIX or Title XXI of the Social Security Act.
(Source: P.A. 91-24, eff. 7-1-99; 92-370, eff. 8-15-01.)
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(305 ILCS 5/15-5) (from Ch. 23, par. 15-5)
Sec. 15-5. Disbursements from the Fund.
(a) The monies in the Fund shall be disbursed only as provided in
Section 15-2 of this Code and as follows:
(1) To the extent that such costs are reimbursable | ||
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(2) To the extent that such costs are reimbursable | ||
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(3) To pay the county hospitals disproportionate | ||
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(3.5) To pay county providers for services provided | ||
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(4) To reimburse the county providers for expenses | ||
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(5) To pay the Illinois Department its necessary | ||
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(6) To pay the county providers any other amount due | ||
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(b) The Illinois Department shall promptly seek all appropriate
amendments to the Illinois Title XIX State Plan to maximize reimbursement, including disproportionate share hospital adjustment payments, to the county providers.
(c) (Blank).
(d) The payments provided for herein are intended to cover services
rendered on and after July 1, 1991, and any agreement executed between a
qualifying county and the Illinois Department pursuant to this Section may
relate back to that date, provided the Illinois Department obtains federal
approval. Any changes in payment rates resulting from the provisions of
Article 3 of this amendatory Act of 1992 are intended to apply to services
rendered on or after October 1, 1992, and any agreement executed between a
qualifying county and the Illinois Department pursuant to this Section may
be effective as of that date.
(e) If one or more hospitals file suit in any court challenging any part
of this Article XV, payments to hospitals from the Fund under this Article
XV shall be made only to the extent that sufficient monies are available in
the Fund and only to the extent that any monies in the Fund are not
prohibited from disbursement and may be disbursed under any order of the court.
(f) All payments under this Section are contingent upon federal
approval of changes to the Title XIX State plan, if that approval is required.
(Source: P.A. 97-687, eff. 6-14-12.)
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(305 ILCS 5/15-6) Sec. 15-6. (Repealed).(Source: P.A. 88-554, eff. 7-26-94. Repealed by P.A. 103-593, eff. 6-7-24; 103-866, eff. 8-9-24.) |
(305 ILCS 5/15-7) (from Ch. 23, par. 15-7)
Sec. 15-7.
Applicability.
The requirements of this Article XV shall
apply only as long as federal funds under Title XIX of the Social Security
Act are available to match the intergovernmental transfer payments made and
disbursed under this Article and only as long as reimbursable expenditures
are matched by the federal government at a rate of at least 50%. Whenever
the Illinois Department is informed that federal funds are not available
for these purposes, or shall be available at a lower percentage, this
Article XV shall no longer apply and the Illinois Department shall promptly
refund to each county provider the amount of money currently
in the Fund that has
been paid by the county provider, plus any investment earnings
on that amount.
(Source: P.A. 87-13; 87-861; 88-554, eff. 7-26-94.)
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(305 ILCS 5/15-8) (from Ch. 23, par. 15-8)
Sec. 15-8. Federal disallowances. In the event of any federal deferral
or disallowance of any federal matching funds obtained through this Article
which have been disbursed by the Illinois Department under this Article
based upon challenges to reimbursement methodologies, the full faith and credit of the county is pledged for
repayment by the county of those amounts deferred or disallowed to the
Illinois Department.
(Source: P.A. 95-859, eff. 8-19-08.)
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(305 ILCS 5/15-9) (from Ch. 23, par. 15-9)
Sec. 15-9.
Waiver of appropriation procedures.
Notwithstanding the
provisions of Sections 6-24001 and 6-24008 of the Counties Code, or any
comparable provision relating to appropriations, the board of commissioners
of qualifying counties may, during each fiscal year, adopt a supplemental
appropriation bill or resolution for expenditures by qualifying counties on
behalf of or by qualifying county hospitals of any funds received hereunder
and the payment of fees to be collected under this Article in an amount
not in excess of any such additional revenue available to that county, or
estimated to be received by that county, subsequent to the adoption of the
annual appropriation bill or resolution for that fiscal year. The
supplemental appropriation bill or resolution shall only affect revenue
that was not available for appropriation when the annual appropriation bill
or resolution was adopted, and the provisions of Section 6-24004 of the
Counties Code or any other comparable provision relating to publication,
notice, and public hearing shall not be applicable to such supplemental
appropriation bill or resolution or to the budget document forming the
basis thereof.
(Source: P.A. 87-13.)
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(305 ILCS 5/15-10) Sec. 15-10. Disproportionate share hospital adjustment payments. (a) The provisions of this Section become operative if: (1) The federal government approves State Plan | ||
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(2) Proposed federal regulations, or other | ||
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(3) The county providers have in good faith submitted | ||
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(4) the county providers maintain and bill for | ||
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The Illinois Department and the county shall include in an intergovernmental agreement the process by which these conditions are assessed. The parties may, if necessary, contract with a large, nationally recognized public accounting firm to carry out this function. (b) If the conditions of subsection (a) are met, and subject to appropriation or other available funding for such purpose, the Illinois Department shall make a payment or otherwise make funds available to the county hospitals, during the lapse period, that provides for total payments to be at least at a level that is equivalent to the total fee-for-service payments received by the county providers that are enrolled with the Illinois Department to provide services during the fiscal year of the payment from the Fund from July 2007 through May 2008 multiplied by twelve-elevenths. (c) In addition, notwithstanding any provision in subsection (a), the Illinois Department shall maximize disproportionate share hospital adjustment payments to the county hospitals that, at a minimum, are 42% of the State's federal fiscal year 2007 disproportionate share allocation. (d) For the purposes of this Section, "net revenues" means the difference between the total fee-for-service payments made by the Illinois Department to county providers less the intergovernmental transfer made by the county in support of those payments. (e) If (i) the disproportionate share hospital adjustment State Plan Amendment referenced in subdivision (a)(1) is not approved, or (ii) any reconciliation of payments to costs incurred would require repayment to the federal government of at least $2,500,000, or (iii) there is no funding available for the Illinois Department's obligations under subsection (b), the Illinois Department, the county, and the leadership of the General Assembly shall designate individuals to convene, within 30 days, to discuss how mutual funding goals for the county providers are to be achieved.
(Source: P.A. 95-859, eff. 8-19-08.) |
(305 ILCS 5/15-11) Sec. 15-11. Uses of State funds. (a) At any point, if State revenues referenced in subsection (b) or (c) of Section 15-10 or additional State grants are disbursed to the Cook County Health and Hospitals System, all funds may be used only for the following: (1) medical services provided at hospitals or clinics | ||
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(2) information technology to enhance billing | ||
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(3) services purchased by county providers pursuant | ||
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(b) State funds may not be used for the following: (1) non-clinical services, except services that may | ||
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(2) non-clinical support staff, except as pursuant to | ||
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(3) capital improvements, other than investments in | ||
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(Source: P.A. 97-687, eff. 6-14-12.) |
(305 ILCS 5/Art. XVI heading) ARTICLE XVI. SURVIVOR SUPPORT AND TRAFFICKING PREVENTION
(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/16-1) Sec. 16-1. Benefits for foreign-born victims of trafficking, torture, or other serious crimes. In order to protect persons who are foreign-born victims of trafficking, torture, or other serious crimes and to reduce the risk of further harm, exploitation, and re-trafficking, beginning January 1, 2018, cash assistance provided under the Temporary Assistance for Needy Families program established under Article IV of this Code and benefits provided under the federal Supplemental Nutrition Assistance Program (SNAP) shall be provided to such persons and their derivative family members to the same extent cash assistance and SNAP benefits are provided to individuals who are admitted to the United States as refugees under Section 1157 of Title 8 of the United States Code. To the extent that federal funding is not available, any cash assistance or SNAP benefits provided under this Article shall be paid from State funds. If changes made in
this Section require federal approval, they shall not take
effect until such approval has been received.
(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/16-2) Sec. 16-2. Eligibility. Subject to available funding, a foreign-born victim of trafficking, torture, or other serious crimes and the individual's derivative family members, but not a single adult without derivative family members, are eligible for cash assistance or SNAP benefits under this Article if the individual: (a) has filed: (1) an application for T Nonimmigrant status with | ||
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(2) a formal application with the appropriate | ||
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(3) a formal application with the appropriate | ||
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(b) is otherwise eligible for cash assistance or SNAP | ||
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An individual residing in an institution or other setting that provides the majority of the individual's daily meals is not eligible for SNAP benefits. (Source: P.A. 103-588, eff. 6-5-24.) |
(305 ILCS 5/16-3) Sec. 16-3. Determination of eligibility. (a) The Department shall determine that an applicant for cash assistance or SNAP benefits provided under this Article is eligible for such benefits if the applicant meets the income guidelines and is otherwise eligible and either: (1) the applicant has filed: (A) an application for T Nonimmigrant status with | ||
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(B) a formal application with the appropriate | ||
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(C) a formal application with the appropriate | ||
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(2) the applicant, or a representative of the | ||
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(A) a sworn statement that he or she is a | ||
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(B) at least one item of additional credible | ||
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(i) police, government agency, or court | ||
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(ii) news articles; (iii) documentation from a social services, | ||
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(iv) a statement from any other individual | ||
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(v) physical evidence; (vi) a copy of a completed visa application; | ||
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(vii) written notice from the federal agency | ||
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(b) The Department may, in its discretion, provide cash assistance or SNAP benefits pursuant to this Article to an applicant who cannot provide additional evidence as set forth in subparagraph (B) of paragraph (2) of subsection (a) if: (1) the applicant, or a representative of the | ||
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(2) the Department determines that the applicant is | ||
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(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/16-4) Sec. 16-4. Work requirements and exemptions. (a) Persons who are foreign-born victims of trafficking, torture, or other serious crimes and who are receiving cash assistance or SNAP benefits under this Article shall be subject to the same work requirements and work requirement exemptions as other recipients of cash assistance or SNAP benefits, provided that compliance with these requirements is authorized by law. (b) A person who is a foreign-born victim of trafficking, torture, or other serious crimes shall be exempted from any work requirements if physical or psychological trauma related to or arising from the trafficking, torture, or other serious crimes impedes his or her ability to comply.
(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/16-5) Sec. 16-5. Termination of benefits. (a) Any cash assistance or SNAP benefits provided under this Article to a person who is a foreign-born victim of trafficking, torture, or other serious crimes and his or her derivative family members shall be terminated if there is a final denial of that person's visa or asylum application under Section 1101(a)(15)(T), 1101(a)(15)(U), or 1158 of Title 8 of the United States Code. (b) A person who is a foreign-born victim of trafficking, torture, or other serious crimes and his or her derivative family members shall be ineligible for continued State-funded cash assistance or SNAP benefits provided under this Article if that person has not filed a formal application for status pursuant to Section 1101(a)(15)(T), 1101(a)(15)(U), or 1158 of Title 8 of the United States Code within one year after the date of his or her application for cash assistance or SNAP benefits provided under this Article. The Department of Human Services may extend the person's and his or her derivative family members' eligibility for medical assistance, cash assistance, or SNAP benefits beyond one year if the Department determines that the person, during the year of initial eligibility (i) experienced a health crisis, (ii) has been unable, after reasonable attempts, to obtain necessary information from a third party, or (iii) has other extenuating circumstances that prevented the person from completing his or her application for status.
(Source: P.A. 99-870, eff. 8-22-16; 100-201, eff. 8-18-17.) |
(305 ILCS 5/16-6) Sec. 16-6. Rulemaking authority. The Department of Human Services shall adopt any rules necessary to implement the provisions of this Article on or before January 1, 2018.
(Source: P.A. 99-870, eff. 8-22-16.) |
(305 ILCS 5/16-7)
Sec. 16-7. (Repealed).
(Source: P.A. 101-246, eff. 8-9-19. Repealed by P.A. 102-31, eff. 6-25-21.)
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