|
interest, safety, or
welfare. |
(b) If any agency finds that an
emergency exists that |
requires adoption of a rule upon fewer days than
is required by |
Section 5-40 and states in writing its reasons for that
|
finding, the agency may adopt an emergency rule without prior |
notice or
hearing upon filing a notice of emergency rulemaking |
with the Secretary of
State under Section 5-70. The notice |
shall include the text of the
emergency rule and shall be |
published in the Illinois Register. Consent
orders or other |
court orders adopting settlements negotiated by an agency
may |
be adopted under this Section. Subject to applicable |
constitutional or
statutory provisions, an emergency rule |
becomes effective immediately upon
filing under Section 5-65 or |
at a stated date less than 10 days
thereafter. The agency's |
finding and a statement of the specific reasons
for the finding |
shall be filed with the rule. The agency shall take
reasonable |
and appropriate measures to make emergency rules known to the
|
persons who may be affected by them. |
(c) An emergency rule may be effective for a period of not |
longer than
150 days, but the agency's authority to adopt an |
identical rule under Section
5-40 is not precluded. No |
emergency rule may be adopted more
than once in any 24 month |
period, except that this limitation on the number
of emergency |
rules that may be adopted in a 24 month period does not apply
|
to (i) emergency rules that make additions to and deletions |
from the Drug
Manual under Section 5-5.16 of the Illinois |
|
Public Aid Code or the
generic drug formulary under Section |
3.14 of the Illinois Food, Drug
and Cosmetic Act, (ii) |
emergency rules adopted by the Pollution Control
Board before |
July 1, 1997 to implement portions of the Livestock Management
|
Facilities Act, (iii) emergency rules adopted by the Illinois |
Department of Public Health under subsections (a) through (i) |
of Section 2 of the Department of Public Health Act when |
necessary to protect the public's health, (iv) emergency rules |
adopted pursuant to subsection (n) of this Section, or (v) |
emergency rules adopted pursuant to subsection (o) of this |
Section. Two or more emergency rules having substantially the |
same
purpose and effect shall be deemed to be a single rule for |
purposes of this
Section. |
(d) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 1999 budget, |
emergency rules to implement any
provision of Public Act 90-587 |
or 90-588
or any other budget initiative for fiscal year 1999 |
may be adopted in
accordance with this Section by the agency |
charged with administering that
provision or initiative, |
except that the 24-month limitation on the adoption
of |
emergency rules and the provisions of Sections 5-115 and 5-125 |
do not apply
to rules adopted under this subsection (d). The |
adoption of emergency rules
authorized by this subsection (d) |
shall be deemed to be necessary for the
public interest, |
safety, and welfare. |
(e) In order to provide for the expeditious and timely |
|
implementation
of the State's fiscal year 2000 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 91st General Assembly
or any other budget initiative |
for fiscal year 2000 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (e). The adoption of emergency rules
authorized by |
this subsection (e) shall be deemed to be necessary for the
|
public interest, safety, and welfare. |
(f) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2001 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 91st General Assembly
or any other budget initiative |
for fiscal year 2001 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (f). The adoption of emergency rules
authorized by |
this subsection (f) shall be deemed to be necessary for the
|
public interest, safety, and welfare. |
(g) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2002 budget, |
emergency rules to implement any
provision of this amendatory |
|
Act of the 92nd General Assembly
or any other budget initiative |
for fiscal year 2002 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (g). The adoption of emergency rules
authorized by |
this subsection (g) shall be deemed to be necessary for the
|
public interest, safety, and welfare. |
(h) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2003 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 92nd General Assembly
or any other budget initiative |
for fiscal year 2003 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (h). The adoption of emergency rules
authorized by |
this subsection (h) shall be deemed to be necessary for the
|
public interest, safety, and welfare. |
(i) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2004 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 93rd General Assembly
or any other budget initiative |
for fiscal year 2004 may be adopted in
accordance with this |
|
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (i). The adoption of emergency rules
authorized by |
this subsection (i) shall be deemed to be necessary for the
|
public interest, safety, and welfare. |
(j) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2005 budget as provided under the Fiscal Year 2005 Budget |
Implementation (Human Services) Act, emergency rules to |
implement any provision of the Fiscal Year 2005 Budget |
Implementation (Human Services) Act may be adopted in |
accordance with this Section by the agency charged with |
administering that provision, except that the 24-month |
limitation on the adoption of emergency rules and the |
provisions of Sections 5-115 and 5-125 do not apply to rules |
adopted under this subsection (j). The Department of Public Aid |
may also adopt rules under this subsection (j) necessary to |
administer the Illinois Public Aid Code and the Children's |
Health Insurance Program Act. The adoption of emergency rules |
authorized by this subsection (j) shall be deemed to be |
necessary for the public interest, safety, and welfare.
|
(k) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2006 budget, emergency rules to implement any provision of this |
|
amendatory Act of the 94th General Assembly or any other budget |
initiative for fiscal year 2006 may be adopted in accordance |
with this Section by the agency charged with administering that |
provision or initiative, except that the 24-month limitation on |
the adoption of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply to rules adopted under this |
subsection (k). The Department of Healthcare and Family |
Services may also adopt rules under this subsection (k) |
necessary to administer the Illinois Public Aid Code, the |
Senior Citizens and Disabled Persons Property Tax Relief and |
Pharmaceutical Assistance Act, the Senior Citizens and |
Disabled Persons Prescription Drug Discount Program Act (now |
the Illinois Prescription Drug Discount Program Act), and the |
Children's Health Insurance Program Act. The adoption of |
emergency rules authorized by this subsection (k) shall be |
deemed to be necessary for the public interest, safety, and |
welfare.
|
(l) In order to provide for the expeditious and timely |
implementation of the provisions of the
State's fiscal year |
2007 budget, the Department of Healthcare and Family Services |
may adopt emergency rules during fiscal year 2007, including |
rules effective July 1, 2007, in
accordance with this |
subsection to the extent necessary to administer the |
Department's responsibilities with respect to amendments to |
the State plans and Illinois waivers approved by the federal |
Centers for Medicare and Medicaid Services necessitated by the |
|
requirements of Title XIX and Title XXI of the federal Social |
Security Act. The adoption of emergency rules
authorized by |
this subsection (l) shall be deemed to be necessary for the |
public interest,
safety, and welfare.
|
(m) In order to provide for the expeditious and timely |
implementation of the provisions of the
State's fiscal year |
2008 budget, the Department of Healthcare and Family Services |
may adopt emergency rules during fiscal year 2008, including |
rules effective July 1, 2008, in
accordance with this |
subsection to the extent necessary to administer the |
Department's responsibilities with respect to amendments to |
the State plans and Illinois waivers approved by the federal |
Centers for Medicare and Medicaid Services necessitated by the |
requirements of Title XIX and Title XXI of the federal Social |
Security Act. The adoption of emergency rules
authorized by |
this subsection (m) shall be deemed to be necessary for the |
public interest,
safety, and welfare.
|
(n) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2010 budget, emergency rules to implement any provision of this |
amendatory Act of the 96th General Assembly or any other budget |
initiative authorized by the 96th General Assembly for fiscal |
year 2010 may be adopted in accordance with this Section by the |
agency charged with administering that provision or |
initiative. The adoption of emergency rules authorized by this |
subsection (n) shall be deemed to be necessary for the public |
|
interest, safety, and welfare. The rulemaking authority |
granted in this subsection (n) shall apply only to rules |
promulgated during Fiscal Year 2010. |
(o) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2011 budget, emergency rules to implement any provision of this |
amendatory Act of the 96th General Assembly or any other budget |
initiative authorized by the 96th General Assembly for fiscal |
year 2011 may be adopted in accordance with this Section by the |
agency charged with administering that provision or |
initiative. The adoption of emergency rules authorized by this |
subsection (o) is deemed to be necessary for the public |
interest, safety, and welfare. The rulemaking authority |
granted in this subsection (o) applies only to rules |
promulgated on or after the effective date of this amendatory |
Act of the 96th General Assembly through June 30, 2011. |
(p) In order to provide for the expeditious and timely |
implementation of the provisions of this amendatory Act of the |
97th General Assembly, emergency rules to implement any |
provision of this amendatory Act of the 97th General Assembly |
may be adopted in accordance with this subsection (p) by the |
agency charged with administering that provision or |
initiative. The 150-day limitation of the effective period of |
emergency rules does not apply to rules adopted under this |
subsection (p), and the effective period may continue through |
June 30, 2013. The 24-month limitation on the adoption of |
|
emergency rules does not apply to rules adopted under this |
subsection (p). The adoption of emergency rules authorized by |
this subsection (p) is deemed to be necessary for the public |
interest, safety, and welfare. |
(Source: P.A. 95-12, eff. 7-2-07; 95-331, eff. 8-21-07; 96-45, |
eff. 7-15-09; 96-958, eff. 7-1-10; 96-1500, eff. 1-18-11.) |
Section 12. The Personnel Code is amended by changing |
Section 4d as follows:
|
(20 ILCS 415/4d) (from Ch. 127, par. 63b104d)
|
Sec. 4d. Partial exemptions. The following positions in |
State service are
exempt from jurisdictions A, B, and C to the |
extent stated for each, unless
those jurisdictions are extended |
as provided in this Act:
|
(1) In each department, board or commission that now |
maintains or may
hereafter maintain a major administrative |
division, service or office in
both Sangamon County and |
Cook County, 2 private secretaries for the
director or |
chairman thereof, one located in the Cook County office and |
the
other located in the Sangamon County office, shall be |
exempt from
jurisdiction B; in all other departments, |
boards and commissions one
private secretary for the |
director or chairman thereof shall be exempt from
|
jurisdiction B. In all departments, boards and commissions |
one confidential
assistant for the director or chairman |
|
thereof shall be exempt from
jurisdiction B. This paragraph |
is subject to such modifications or waiver
of the |
exemptions as may be necessary to assure the continuity of |
federal
contributions in those agencies supported in whole |
or in part by federal
funds.
|
(2) The resident administrative head of each State |
charitable, penal and
correctional institution, the |
chaplains thereof, and all member, patient
and inmate |
employees are exempt from jurisdiction B.
|
(3) The Civil Service Commission, upon written |
recommendation of the
Director of Central Management |
Services, shall exempt
from jurisdiction B other positions
|
which, in the judgment of the Commission, involve either |
principal
administrative responsibility for the |
determination of policy or principal
administrative |
responsibility for the way in which policies are carried
|
out, except positions in agencies which receive federal |
funds if such
exemption is inconsistent with federal |
requirements, and except positions
in agencies supported |
in whole by federal funds.
|
(4) All beauticians and teachers of beauty culture and |
teachers of
barbering, and all positions heretofore paid |
under Section 1.22 of "An Act
to standardize position |
titles and salary rates", approved June 30, 1943,
as |
amended, shall be exempt from jurisdiction B.
|
(5) Licensed attorneys in positions as legal or |
|
technical advisors, positions in the Department of Natural |
Resources requiring incumbents
to be either a registered |
professional engineer or to hold a bachelor's degree
in |
engineering from a recognized college or university,
|
licensed physicians in positions of medical administrator |
or physician or
physician specialist (including |
psychiatrists), and registered nurses (except
those |
registered nurses employed by the Department of Public |
Health), except
those in positions in agencies which |
receive federal funds if such
exemption is inconsistent |
with federal requirements and except those in
positions in |
agencies supported in whole by federal funds, are exempt |
from
jurisdiction B only to the extent that the |
requirements of Section 8b.1,
8b.3 and 8b.5 of this Code |
need not be met.
|
(6) All positions established outside the geographical |
limits of the
State of Illinois to which appointments of |
other than Illinois citizens may
be made are exempt from |
jurisdiction B.
|
(7) Staff attorneys reporting directly to individual |
Commissioners of
the Illinois Workers' Compensation
|
Commission are exempt from jurisdiction B.
|
(8) Twenty-one Twenty senior public service |
administrator positions within the Department of |
Healthcare and Family Services, as set forth in this |
paragraph (8), requiring the specific knowledge of |
|
healthcare administration, healthcare finance, healthcare |
data analytics, or information technology described are |
exempt from jurisdiction B only to the extent that the |
requirements of Sections 8b.1, 8b.3, and 8b.5 of this Code |
need not be met. The General Assembly finds that these |
positions are all senior policy makers and have |
spokesperson authority for the Director of the Department |
of Healthcare and Family Services. When filling positions |
so designated, the Director of Healthcare and Family |
Services shall cause a position description to be published |
which allots points to various qualifications desired. |
After scoring qualified applications, the Director shall |
add Veteran's Preference points as enumerated in Section |
8b.7 of this Code. The following are the minimum |
qualifications for the senior public service administrator |
positions provided for in this paragraph (8): |
(A) HEALTHCARE ADMINISTRATION. |
Medical Director: Licensed Medical Doctor in |
good standing; experience in healthcare payment |
systems, pay for performance initiatives, medical |
necessity criteria or federal or State quality |
improvement programs; preferred experience serving |
Medicaid patients or experience in population |
health programs with a large provider, health |
insurer, government agency, or research |
institution. |
|
Chief, Bureau of Quality Management: Advanced |
degree in health policy or health professional |
field preferred; at least 3 years experience in |
implementing or managing healthcare quality |
improvement initiatives in a clinical setting. |
Quality Management Bureau: Manager, Care |
Coordination/Managed Care Quality: Clinical degree |
or advanced degree in relevant field required; |
experience in the field of managed care quality |
improvement, with knowledge of HEDIS measurements, |
coding, and related data definitions. |
Quality Management Bureau: Manager, Primary |
Care Provider Quality and Practice Development: |
Clinical degree or advanced degree in relevant |
field required; experience in practice |
administration in the primary care setting with a |
provider or a provider association or an |
accrediting body; knowledge of practice standards |
for medical homes and best evidence based |
standards of care for primary care. |
Director of Care Coordination Contracts and |
Compliance: Bachelor's degree required; multi-year |
experience in negotiating managed care contracts, |
preferably on behalf of a payer; experience with |
health care contract compliance. |
Manager, Long Term Care Policy: Bachelor's |
|
degree required; social work, gerontology, or |
social service degree preferred; knowledge of |
Olmstead and other relevant court decisions |
required; experience working with diverse long |
term care populations and service systems, federal |
initiatives to create long term care community |
options, and home and community-based waiver |
services required. The General Assembly finds that |
this position is necessary for the timely and |
effective implementation of this amendatory Act of |
the 97th General Assembly. |
Manager, Behavioral Health Programs: Clinical |
license or Advanced degree required, preferably in |
psychology, social work, or relevant field; |
knowledge of medical necessity criteria and |
governmental policies and regulations governing |
the provision of mental health services to |
Medicaid populations, including children and |
adults, in community and institutional settings of |
care. The General Assembly finds that this |
position is necessary for the timely and effective |
implementation of this amendatory Act of the 97th |
General Assembly. |
Chief, Bureau of Pharmacy Services: Bachelor's |
degree required; pharmacy degree preferred; in |
formulary development and management from both a |
|
clinical and financial perspective, experience in |
prescription drug utilization review and |
utilization control policies, knowledge of retail |
pharmacy reimbursement policies and methodologies |
and available benchmarks, knowledge of Medicare |
Part D benefit design. |
Chief, Bureau of Maternal and Child Health |
Promotion: Bachelor's degree required, advanced |
degree preferred, in public health, health care |
management, or a clinical field; multi-year |
experience in health care or public health |
management; knowledge of federal EPSDT |
requirements and strategies for improving health |
care for children as well as improving birth |
outcomes. |
Director of Dental Program: Bachelor's degree |
required, advanced degree preferred, in healthcare |
management or relevant field; experience in |
healthcare administration; experience in |
administering dental healthcare programs, |
knowledge of practice standards for dental care |
and treatment services; knowledge of the public |
dental health infrastructure. |
Manager of Medicare/Medicaid Coordination: |
Bachelor's degree required, knowledge and |
experience with Medicare Advantage rules and |
|
regulations, knowledge of Medicaid laws and |
policies; experience with contract drafting |
preferred. |
Chief, Bureau of Eligibility Integrity: |
Bachelor's degree required, advanced degree in |
public administration or business administration |
preferred; experience equivalent to 4 years of |
administration in a public or business |
organization required; experience with managing |
contract compliance required; knowledge of |
Medicaid eligibility laws and policy preferred; |
supervisory experience preferred. The General |
Assembly finds that this position is necessary for |
the timely and effective implementation of this |
amendatory Act of the 97th General Assembly. |
(B) HEALTHCARE FINANCE. |
Director of Care Coordination Rate and |
Finance: MBA, CPA, or Actuarial degree required; |
experience in managed care rate setting, |
including, but not limited to, baseline costs and |
growth trends; knowledge and experience with |
Medical Loss Ratio standards and measurements. |
Director of Encounter Data Program: Bachelor's |
degree required, advanced degree preferred, |
preferably in business or information systems; at |
least 2 years healthcare data reporting |
|
experience, including, but not limited to, data |
definitions, submission, and editing; strong |
background in HIPAA transactions relevant to |
encounter data submission; knowledge of healthcare |
claims systems. |
Chief, Bureau of Rate Development and |
Analysis: Bachelor's degree required, advanced |
degree preferred, with preferred coursework in |
business or public administration, accounting, |
finance, data analysis, or statistics; experience |
with Medicaid reimbursement methodologies and |
regulations; experience with extracting data from |
large systems for analysis. |
Manager of Medical Finance, Division of |
Finance: Requires relevant advanced degree or |
certification in relevant field, such as Certified |
Public Accountant; coursework in business or |
public administration, accounting, finance, data |
analysis, or statistics preferred; experience in |
control systems and GAAP; financial management |
experience in a healthcare or government entity |
utilizing Medicaid funding. |
(C) HEALTHCARE DATA ANALYTICS. |
Data Quality Assurance Manager: Bachelor's |
degree required, advanced degree preferred, |
preferably in business, information systems, or |
|
epidemiology; at least 3 years of extensive |
healthcare data reporting experience with a large |
provider, health insurer, government agency, or |
research institution; previous data quality |
assurance role or formal data quality assurance |
training. |
Data Analytics Unit Manager: Bachelor's degree |
required, advanced degree preferred, in |
information systems, applied mathematics, or |
another field with a strong analytics component; |
extensive healthcare data reporting experience |
with a large provider, health insurer, government |
agency, or research institution; experience as a |
business analyst interfacing between business and |
information technology departments; in-depth |
knowledge of health insurance coding and evolving |
healthcare quality metrics; working knowledge of |
SQL and/or SAS. |
Data Analytics Platform Manager: Bachelor's |
degree required, advanced degree preferred, |
preferably in business or information systems; |
extensive healthcare data reporting experience |
with a large provider, health insurer, government |
agency, or research institution; previous |
experience working on a health insurance data |
analytics platform; experience managing contracts |
|
and vendors preferred. |
(D) HEALTHCARE INFORMATION TECHNOLOGY. |
Manager of Recipient Provider Reference Unit: |
Bachelor's degree required; experience equivalent |
to 4 years of administration in a public or |
business organization; 3 years of administrative |
experience in a computer-based management |
information system. |
Manager of MMIS Claims Unit: Bachelor's degree |
required, with preferred coursework in business, |
public administration, information systems; |
experience equivalent to 4 years of administration |
in a public or business organization; working |
knowledge with design and implementation of |
technical solutions to medical claims payment |
systems; extensive technical writing experience, |
including, but not limited to, the development of |
RFPs, APDs, feasibility studies, and related |
documents; thorough knowledge of IT system design, |
commercial off the shelf software packages and |
hardware components. |
Assistant Bureau Chief, Office of Information |
Systems: Bachelor's degree required, with |
preferred coursework in business, public |
administration, information systems; experience |
equivalent to 5 years of administration in a public |
|
or private business organization; extensive |
technical writing experience, including, but not |
limited to, the development of RFPs, APDs, |
feasibility studies and related documents; |
extensive healthcare technology experience with a |
large provider, health insurer, government agency, |
or research institution; experience as a business |
analyst interfacing between business and |
information technology departments; thorough |
knowledge of IT system design, commercial off the |
shelf software packages and hardware components. |
Technical System Architect: Bachelor's degree |
required, with preferred coursework in computer |
science or information technology; prior |
experience equivalent to 5 years of computer |
science or IT administration in a public or |
business organization; extensive healthcare |
technology experience with a large provider, |
health insurer, government agency, or research |
institution; experience as a business analyst |
interfacing between business and information |
technology departments. |
The provisions of this paragraph (8), other than this |
sentence, are inoperative after January 1, 2014. |
(Source: P.A. 97-649, eff. 12-30-11.)
|
|
Section 14. The Illinois State Auditing Act is amended by |
adding Section 2-20 as follows: |
(30 ILCS 5/2-20 new) |
Sec. 2-20. Certification of federal waivers and amendments |
to the Illinois Title XIX State plan. |
(a) No later than August 1, 2012, the Department shall file |
a report with the Auditor General, 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 listing any necessary amendment to the Illinois |
Title XIX State plan, federal waiver request, or State |
administrative rule required to implement this amendatory Act |
of the 97th General Assembly. |
(b) No later than March 1, 2013, the Department shall |
provide evidence to the Auditor General that it has undertaken |
the required actions listed in the report required by |
subsection (a). |
(c) No later than May 1, 2013, the Auditor General shall |
submit a report 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 as to whether the Department has undertaken the required |
actions listed in the report required by subsection (a). |
Section 15. The State Finance Act is amended by changing |
|
Sections 6z-52 and 13.2 as follows:
|
(30 ILCS 105/6z-52)
|
Sec. 6z-52. Drug Rebate Fund.
|
(a) There is created in the State Treasury a special fund |
to be known as
the Drug Rebate Fund.
|
(b) The Fund is created for the purpose of receiving and |
disbursing moneys
in accordance with this Section. |
Disbursements from the Fund shall be made,
subject to |
appropriation, only as follows:
|
(1) For payments for reimbursement or coverage for |
prescription drugs and other pharmacy products
provided to |
a recipient of medical assistance under the Illinois Public |
Aid Code, the Children's Health Insurance Program Act, the |
Covering ALL KIDS Health Insurance Act, and the Veterans' |
Health Insurance Program Act of 2008 , and the Senior |
Citizens and Disabled Persons Property Tax Relief and |
Pharmaceutical Assistance Act .
|
(2) For reimbursement of moneys collected by the |
Department of Healthcare and Family Services (formerly
|
Illinois Department of
Public Aid) through error or |
mistake.
|
(3) For payments of any amounts that are reimbursable |
to the federal
government resulting from a payment into |
this Fund.
|
(4) For payments of operational and administrative |
|
expenses related to providing and managing coverage for |
prescription drugs and other pharmacy products provided to |
a recipient of medical assistance under the Illinois Public |
Aid Code, the Children's Health Insurance Program Act, the |
Covering ALL KIDS Health Insurance Act, the Veterans' |
Health Insurance Program Act of 2008, and the Senior |
Citizens and Disabled Persons Property Tax Relief and |
Pharmaceutical Assistance Act. |
(c) The Fund shall consist of the following:
|
(1) Upon notification from the Director of Healthcare |
and Family Services, the Comptroller
shall direct and the |
Treasurer shall transfer the net State share (disregarding |
the reduction in net State share attributable to the |
American Recovery and Reinvestment Act of 2009 or any other |
federal economic stimulus program) of all moneys
received |
by the Department of Healthcare and Family Services |
(formerly Illinois Department of Public Aid) from drug |
rebate agreements
with pharmaceutical manufacturers |
pursuant to Title XIX of the federal Social
Security Act, |
including any portion of the balance in the Public Aid |
Recoveries
Trust Fund on July 1, 2001 that is attributable |
to such receipts.
|
(2) All federal matching funds received by the Illinois |
Department as a
result of expenditures made by the |
Department that are attributable to moneys
deposited in the |
Fund.
|
|
(3) Any premium collected by the Illinois Department |
from participants
under a waiver approved by the federal |
government relating to provision of
pharmaceutical |
services.
|
(4) All other moneys received for the Fund from any |
other source,
including interest earned thereon.
|
(Source: P.A. 95-331, eff. 8-21-07; 96-8, eff. 4-28-09; |
96-1100, eff. 1-1-11.)
|
(30 ILCS 105/13.2) (from Ch. 127, par. 149.2)
|
Sec. 13.2. Transfers among line item appropriations. |
(a) Transfers among line item appropriations from the same
|
treasury fund for the objects specified in this Section may be |
made in
the manner provided in this Section when the balance |
remaining in one or
more such line item appropriations is |
insufficient for the purpose for
which the appropriation was |
made. |
(a-1) No transfers may be made from one
agency to another |
agency, nor may transfers be made from one institution
of |
higher education to another institution of higher education |
except as provided by subsection (a-4).
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(a-2) Except as otherwise provided in this Section, |
transfers may be made only among the objects of expenditure |
enumerated
in this Section, except that no funds may be |
transferred from any
appropriation for personal services, from |
any appropriation for State
contributions to the State |
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Employees' Retirement System, from any
separate appropriation |
for employee retirement contributions paid by the
employer, nor |
from any appropriation for State contribution for
employee |
group insurance. During State fiscal year 2005, an agency may |
transfer amounts among its appropriations within the same |
treasury fund for personal services, employee retirement |
contributions paid by employer, and State Contributions to |
retirement systems; notwithstanding and in addition to the |
transfers authorized in subsection (c) of this Section, the |
fiscal year 2005 transfers authorized in this sentence may be |
made in an amount not to exceed 2% of the aggregate amount |
appropriated to an agency within the same treasury fund. During |
State fiscal year 2007, the Departments of Children and Family |
Services, Corrections, Human Services, and Juvenile Justice |
may transfer amounts among their respective appropriations |
within the same treasury fund for personal services, employee |
retirement contributions paid by employer, and State |
contributions to retirement systems. During State fiscal year |
2010, the Department of Transportation may transfer amounts |
among their respective appropriations within the same treasury |
fund for personal services, employee retirement contributions |
paid by employer, and State contributions to retirement |
systems. During State fiscal year 2010 only, an agency may |
transfer amounts among its respective appropriations within |
the same treasury fund for personal services, employee |
retirement contributions paid by employer, and State |
|
contributions to retirement systems. Notwithstanding, and in |
addition to, the transfers authorized in subsection (c) of this |
Section, these transfers may be made in an amount not to exceed |
2% of the aggregate amount appropriated to an agency within the |
same treasury fund.
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(a-3) Further, if an agency receives a separate
|
appropriation for employee retirement contributions paid by |
the employer,
any transfer by that agency into an appropriation |
for personal services
must be accompanied by a corresponding |
transfer into the appropriation for
employee retirement |
contributions paid by the employer, in an amount
sufficient to |
meet the employer share of the employee contributions
required |
to be remitted to the retirement system. |
(a-4) Long-Term Care Rebalancing. The Governor may |
designate amounts set aside for institutional services |
appropriated from the General Revenue Fund or any other State |
fund that receives monies for long-term care services to be |
transferred to all State agencies responsible for the |
administration of community-based long-term care programs, |
including, but not limited to, community-based long-term care |
programs administered by the Department of Healthcare and |
Family Services, the Department of Human Services, and the |
Department on Aging, provided that the Director of Healthcare |
and Family Services first certifies that the amounts being |
transferred are necessary for the purpose of assisting persons |
in or at risk of being in institutional care to transition to |
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community-based settings, including the financial data needed |
to prove the need for the transfer of funds. The total amounts |
transferred shall not exceed 4% in total of the amounts |
appropriated from the General Revenue Fund or any other State |
fund that receives monies for long-term care services for each |
fiscal year. A notice of the fund transfer must be made to the |
General Assembly and posted at a minimum on the Department of |
Healthcare and Family Services website, the Governor's Office |
of Management and Budget website, and any other website the |
Governor sees fit. These postings shall serve as notice to the |
General Assembly of the amounts to be transferred. Notice shall |
be given at least 30 days prior to transfer. |
(b) In addition to the general transfer authority provided |
under
subsection (c), the following agencies have the specific |
transfer authority
granted in this subsection: |
The Department of Healthcare and Family Services is |
authorized to make transfers
representing savings attributable |
to not increasing grants due to the
births of additional |
children from line items for payments of cash grants to
line |
items for payments for employment and social services for the |
purposes
outlined in subsection (f) of Section 4-2 of the |
Illinois Public Aid Code. |
The Department of Children and Family Services is |
authorized to make
transfers not exceeding 2% of the aggregate |
amount appropriated to it within
the same treasury fund for the |
following line items among these same line
items: Foster Home |
|
and Specialized Foster Care and Prevention, Institutions
and |
Group Homes and Prevention, and Purchase of Adoption and |
Guardianship
Services. |
The Department on Aging is authorized to make transfers not
|
exceeding 2% of the aggregate amount appropriated to it within |
the same
treasury fund for the following Community Care Program |
line items among these
same line items: Homemaker and Senior |
Companion Services, Alternative Senior Services, Case |
Coordination
Units, and Adult Day Care Services. |
The State Treasurer is authorized to make transfers among |
line item
appropriations
from the Capital Litigation Trust |
Fund, with respect to costs incurred in
fiscal years 2002 and |
2003 only, when the balance remaining in one or
more such
line |
item appropriations is insufficient for the purpose for which |
the
appropriation was
made, provided that no such transfer may |
be made unless the amount transferred
is no
longer required for |
the purpose for which that appropriation was made. |
The State Board of Education is authorized to make |
transfers from line item appropriations within the same |
treasury fund for General State Aid and General State Aid - |
Hold Harmless, provided that no such transfer may be made |
unless the amount transferred is no longer required for the |
purpose for which that appropriation was made, to the line item |
appropriation for Transitional Assistance when the balance |
remaining in such line item appropriation is insufficient for |
the purpose for which the appropriation was made. |
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The State Board of Education is authorized to make |
transfers between the following line item appropriations |
within the same treasury fund: Disabled Student |
Services/Materials (Section 14-13.01 of the School Code), |
Disabled Student Transportation Reimbursement (Section |
14-13.01 of the School Code), Disabled Student Tuition - |
Private Tuition (Section 14-7.02 of the School Code), |
Extraordinary Special Education (Section 14-7.02b of the |
School Code), Reimbursement for Free Lunch/Breakfast Program, |
Summer School Payments (Section 18-4.3 of the School Code), and |
Transportation - Regular/Vocational Reimbursement (Section |
29-5 of the School Code). Such transfers shall be made only |
when the balance remaining in one or more such line item |
appropriations is insufficient for the purpose for which the |
appropriation was made and provided that no such transfer may |
be made unless the amount transferred is no longer required for |
the purpose for which that appropriation was made. |
The During State fiscal years 2010 and 2011 only, the |
Department of Healthcare and Family Services is authorized to |
make transfers not exceeding 4% of the aggregate amount |
appropriated to it, within the same treasury fund, among the |
various line items appropriated for Medical Assistance. |
(c) The sum of such transfers for an agency in a fiscal |
year shall not
exceed 2% of the aggregate amount appropriated |
to it within the same treasury
fund for the following objects: |
Personal Services; Extra Help; Student and
Inmate |
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Compensation; State Contributions to Retirement Systems; State
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Contributions to Social Security; State Contribution for |
Employee Group
Insurance; Contractual Services; Travel; |
Commodities; Printing; Equipment;
Electronic Data Processing; |
Operation of Automotive Equipment;
Telecommunications |
Services; Travel and Allowance for Committed, Paroled
and |
Discharged Prisoners; Library Books; Federal Matching Grants |
for
Student Loans; Refunds; Workers' Compensation, |
Occupational Disease, and
Tort Claims; and, in appropriations |
to institutions of higher education,
Awards and Grants. |
Notwithstanding the above, any amounts appropriated for
|
payment of workers' compensation claims to an agency to which |
the authority
to evaluate, administer and pay such claims has |
been delegated by the
Department of Central Management Services |
may be transferred to any other
expenditure object where such |
amounts exceed the amount necessary for the
payment of such |
claims. |
(c-1) Special provisions for State fiscal year 2003. |
Notwithstanding any
other provision of this Section to the |
contrary, for State fiscal year 2003
only, transfers among line |
item appropriations to an agency from the same
treasury fund |
may be made provided that the sum of such transfers for an |
agency
in State fiscal year 2003 shall not exceed 3% of the |
aggregate amount
appropriated to that State agency for State |
fiscal year 2003 for the following
objects: personal services, |
except that no transfer may be approved which
reduces the |
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aggregate appropriations for personal services within an |
agency;
extra help; student and inmate compensation; State
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contributions to retirement systems; State contributions to |
social security;
State contributions for employee group |
insurance; contractual services; travel;
commodities; |
printing; equipment; electronic data processing; operation of
|
automotive equipment; telecommunications services; travel and |
allowance for
committed, paroled, and discharged prisoners; |
library books; federal matching
grants for student loans; |
refunds; workers' compensation, occupational disease,
and tort |
claims; and, in appropriations to institutions of higher |
education,
awards and grants. |
(c-2) Special provisions for State fiscal year 2005. |
Notwithstanding subsections (a), (a-2), and (c), for State |
fiscal year 2005 only, transfers may be made among any line |
item appropriations from the same or any other treasury fund |
for any objects or purposes, without limitation, when the |
balance remaining in one or more such line item appropriations |
is insufficient for the purpose for which the appropriation was |
made, provided that the sum of those transfers by a State |
agency shall not exceed 4% of the aggregate amount appropriated |
to that State agency for fiscal year 2005.
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(d) Transfers among appropriations made to agencies of the |
Legislative
and Judicial departments and to the |
constitutionally elected officers in the
Executive branch |
require the approval of the officer authorized in Section 10
of |
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this Act to approve and certify vouchers. Transfers among |
appropriations
made to the University of Illinois, Southern |
Illinois University, Chicago State
University, Eastern |
Illinois University, Governors State University, Illinois
|
State University, Northeastern Illinois University, Northern |
Illinois
University, Western Illinois University, the Illinois |
Mathematics and Science
Academy and the Board of Higher |
Education require the approval of the Board of
Higher Education |
and the Governor. Transfers among appropriations to all other
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agencies require the approval of the Governor. |
The officer responsible for approval shall certify that the
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transfer is necessary to carry out the programs and purposes |
for which
the appropriations were made by the General Assembly |
and shall transmit
to the State Comptroller a certified copy of |
the approval which shall
set forth the specific amounts |
transferred so that the Comptroller may
change his records |
accordingly. The Comptroller shall furnish the
Governor with |
information copies of all transfers approved for agencies
of |
the Legislative and Judicial departments and transfers |
approved by
the constitutionally elected officials of the |
Executive branch other
than the Governor, showing the amounts |
transferred and indicating the
dates such changes were entered |
on the Comptroller's records. |
(e) The State Board of Education, in consultation with the |
State Comptroller, may transfer line item appropriations for |
General State Aid between the Common School Fund and the |
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Education Assistance Fund. With the advice and consent of the |
Governor's Office of Management and Budget, the State Board of |
Education, in consultation with the State Comptroller, may |
transfer line item appropriations between the General Revenue |
Fund and the Education Assistance Fund for the following |
programs: |
(1) Disabled Student Personnel Reimbursement (Section |
14-13.01 of the School Code); |
(2) Disabled Student Transportation Reimbursement |
(subsection (b) of Section 14-13.01 of the School Code); |
(3) Disabled Student Tuition - Private Tuition |
(Section 14-7.02 of the School Code); |
(4) Extraordinary Special Education (Section 14-7.02b |
of the School Code); |
(5) Reimbursement for Free Lunch/Breakfast Programs; |
(6) Summer School Payments (Section 18-4.3 of the |
School Code); |
(7) Transportation - Regular/Vocational Reimbursement |
(Section 29-5 of the School Code); |
(8) Regular Education Reimbursement (Section 18-3 of |
the School Code); and |
(9) Special Education Reimbursement (Section 14-7.03 |
of the School Code). |
(Source: P.A. 95-707, eff. 1-11-08; 96-37, eff. 7-13-09; |
96-820, eff. 11-18-09; 96-959, eff. 7-1-10; 96-1086, eff. |
7-16-10; 96-1501, eff. 1-25-11.)
|
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(30 ILCS 105/5.441 rep.) |
(30 ILCS 105/5.442 rep.) |
(30 ILCS 105/5.549 rep.) |
Section 20. The State Finance Act is amended by repealing |
Sections 5.441, 5.442, and 5.549. |
Section 25. The Illinois Procurement Code is amended by |
changing Section 1-10 as follows:
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(30 ILCS 500/1-10)
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Sec. 1-10. Application.
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(a) This Code applies only to procurements for which |
contractors were first
solicited on or after July 1, 1998. This |
Code shall not be construed to affect
or impair any contract, |
or any provision of a contract, entered into based on a
|
solicitation prior to the implementation date of this Code as |
described in
Article 99, including but not limited to any |
covenant entered into with respect
to any revenue bonds or |
similar instruments.
All procurements for which contracts are |
solicited between the effective date
of Articles 50 and 99 and |
July 1, 1998 shall be substantially in accordance
with this |
Code and its intent.
|
(b) This Code shall apply regardless of the source of the |
funds with which
the contracts are paid, including federal |
assistance moneys.
This Code shall
not apply to:
|
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(1) Contracts between the State and its political |
subdivisions or other
governments, or between State |
governmental bodies except as specifically
provided in |
this Code.
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(2) Grants, except for the filing requirements of |
Section 20-80.
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(3) Purchase of care.
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(4) Hiring of an individual as employee and not as an |
independent
contractor, whether pursuant to an employment |
code or policy or by contract
directly with that |
individual.
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(5) Collective bargaining contracts.
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(6) Purchase of real estate, except that notice of this |
type of contract with a value of more than $25,000 must be |
published in the Procurement Bulletin within 7 days after |
the deed is recorded in the county of jurisdiction. The |
notice shall identify the real estate purchased, the names |
of all parties to the contract, the value of the contract, |
and the effective date of the contract.
|
(7) Contracts necessary to prepare for anticipated |
litigation, enforcement
actions, or investigations, |
provided
that the chief legal counsel to the Governor shall |
give his or her prior
approval when the procuring agency is |
one subject to the jurisdiction of the
Governor, and |
provided that the chief legal counsel of any other |
procuring
entity
subject to this Code shall give his or her |
|
prior approval when the procuring
entity is not one subject |
to the jurisdiction of the Governor.
|
(8) Contracts for
services to Northern Illinois |
University by a person, acting as
an independent |
contractor, who is qualified by education, experience, and
|
technical ability and is selected by negotiation for the |
purpose of providing
non-credit educational service |
activities or products by means of specialized
programs |
offered by the university.
|
(9) Procurement expenditures by the Illinois |
Conservation Foundation
when only private funds are used.
|
(10) Procurement expenditures by the Illinois Health |
Information Exchange Authority involving private funds |
from the Health Information Exchange Fund. "Private funds" |
means gifts, donations, and private grants. |
(11) Public-private agreements entered into according |
to the procurement requirements of Section 20 of the |
Public-Private Partnerships for Transportation Act and |
design-build agreements entered into according to the |
procurement requirements of Section 25 of the |
Public-Private Partnerships for Transportation Act. |
(c) This Code does not apply to the electric power |
procurement process provided for under Section 1-75 of the |
Illinois Power Agency Act and Section 16-111.5 of the Public |
Utilities Act. |
(d) Except for Section 20-160 and Article 50 of this Code, |
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and as expressly required by Section 9.1 of the Illinois |
Lottery Law, the provisions of this Code do not apply to the |
procurement process provided for under Section 9.1 of the |
Illinois Lottery Law. |
(e) This Code does not apply to the process used by the |
Capital Development Board to retain a person or entity to |
assist the Capital Development Board with its duties related to |
the determination of costs of a clean coal SNG brownfield |
facility, as defined by Section 1-10 of the Illinois Power |
Agency Act, as required in subsection (h-3) of Section 9-220 of |
the Public Utilities Act, including calculating the range of |
capital costs, the range of operating and maintenance costs, or |
the sequestration costs or monitoring the construction of clean |
coal SNG brownfield facility for the full duration of |
construction. |
(f) This Code does not apply to the process used by the |
Illinois Power Agency to retain a mediator to mediate sourcing |
agreement disputes between gas utilities and the clean coal SNG |
brownfield facility, as defined in Section 1-10 of the Illinois |
Power Agency Act, as required under subsection (h-1) of Section |
9-220 of the Public Utilities Act. |
(g) (e) This Code does not apply to the processes used by |
the Illinois Power Agency to retain a mediator to mediate |
contract disputes between gas utilities and the clean coal SNG |
facility and to retain an expert to assist in the review of |
contracts under subsection (h) of Section 9-220 of the Public |
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Utilities Act. This Code does not apply to the process used by |
the Illinois Commerce Commission to retain an expert to assist |
in determining the actual incurred costs of the clean coal SNG |
facility and the reasonableness of those costs as required |
under subsection (h) of Section 9-220 of the Public Utilities |
Act. |
(h) This Code does not apply to the process to procure or |
contracts entered into in accordance with Sections 11-5.2 and |
11-5.3 of the Illinois Public Aid Code. |
(Source: P.A. 96-840, eff. 12-23-09; 96-1331, eff. 7-27-10; |
97-96, eff. 7-13-11; 97-239, eff. 8-2-11; 97-502, eff. 8-23-11; |
revised 9-7-11.)
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(30 ILCS 775/Act rep.)
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Section 30. The Excellence in Academic Medicine Act is |
repealed. |
Section 45. The Nursing Home Care Act is amended by |
changing Section 3-202.05 as follows: |
(210 ILCS 45/3-202.05) |
Sec. 3-202.05. Staffing ratios effective July 1, 2010 and |
thereafter. |
(a) For the purpose of computing staff to resident ratios, |
direct care staff shall include: |
(1) registered nurses; |
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(2) licensed practical nurses; |
(3) certified nurse assistants; |
(4) psychiatric services rehabilitation aides; |
(5) rehabilitation and therapy aides; |
(6) psychiatric services rehabilitation coordinators; |
(7) assistant directors of nursing; |
(8) 50% of the Director of Nurses' time; and |
(9) 30% of the Social Services Directors' time. |
The Department shall, by rule, allow certain facilities |
subject to 77 Ill. Admin. Code 300.4000 and following (Subpart |
S) and 300.6000 and following (Subpart T) to utilize |
specialized clinical staff, as defined in rules, to count |
towards the staffing ratios. |
Within 120 days of the effective date of this amendatory |
Act of the 97th General Assembly, the Department shall |
promulgate rules specific to the staffing requirements for |
facilities federally defined as Institutions for Mental |
Disease. These rules shall recognize the unique nature of |
individuals with chronic mental health conditions, shall |
include minimum requirements for specialized clinical staff, |
including clinical social workers, psychiatrists, |
psychologists, and direct care staff set forth in paragraphs |
(4) through (6) and any other specialized staff which may be |
utilized and deemed necessary to count toward staffing ratios. |
Within 120 days of the effective date of this amendatory |
Act of the 97th General Assembly, the Department shall |
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promulgate rules specific to the staffing requirements for |
facilities licensed under the Specialized Mental Health |
Rehabilitation Act. These rules shall recognize the unique |
nature of individuals with chronic mental health conditions, |
shall include minimum requirements for specialized clinical |
staff, including clinical social workers, psychiatrists, |
psychologists, and direct care staff set forth in paragraphs |
(4) through (6) and any other specialized staff which may be |
utilized and deemed necessary to count toward staffing ratios. |
(b) Beginning January 1, 2011, and thereafter, light |
intermediate care shall be staffed at the same staffing ratio |
as intermediate care. |
(c) Facilities shall notify the Department within 60 days |
after the effective date of this amendatory Act of the 96th |
General Assembly, in a form and manner prescribed by the |
Department, of the staffing ratios in effect on the effective |
date of this amendatory Act of the 96th General Assembly for |
both intermediate and skilled care and the number of residents |
receiving each level of care. |
(d)(1) Effective July 1, 2010, for each resident needing |
skilled care, a minimum staffing ratio of 2.5 hours of nursing |
and personal care each day must be provided; for each resident |
needing intermediate care, 1.7 hours of nursing and personal |
care each day must be provided. |
(2) Effective January 1, 2011, the minimum staffing ratios |
shall be increased to 2.7 hours of nursing and personal care |
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each day for a resident needing skilled care and 1.9 hours of |
nursing and personal care each day for a resident needing |
intermediate care. |
(3) Effective January 1, 2012, the minimum staffing ratios |
shall be increased to 3.0 hours of nursing and personal care |
each day for a resident needing skilled care and 2.1 hours of |
nursing and personal care each day for a resident needing |
intermediate care. |
(4) Effective January 1, 2013, the minimum staffing ratios |
shall be increased to 3.4 hours of nursing and personal care |
each day for a resident needing skilled care and 2.3 hours of |
nursing and personal care each day for a resident needing |
intermediate care. |
(5) Effective January 1, 2014, the minimum staffing ratios |
shall be increased to 3.8 hours of nursing and personal care |
each day for a resident needing skilled care and 2.5 hours of |
nursing and personal care each day for a resident needing |
intermediate care.
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(e) Ninety days after the effective date of this amendatory |
Act of the 97th General Assembly, a minimum of 25% of nursing |
and personal care time shall be provided by licensed nurses, |
with at least 10% of nursing and personal care time provided by |
registered nurses. These minimum requirements shall remain in |
effect until an acuity based registered nurse requirement is |
promulgated by rule concurrent with the adoption of the |
Resource Utilization Group classification-based payment |
|
methodology, as provided in Section 5-5.2 of the Illinois |
Public Aid Code. Registered nurses and licensed practical |
nurses employed by a facility in excess of these requirements |
may be used to satisfy the remaining 75% of the nursing and |
personal care time requirements. Notwithstanding this |
subsection, no staffing requirement in statute in effect on the |
effective date of this amendatory Act of the 97th General |
Assembly shall be reduced on account of this subsection. |
(Source: P.A. 96-1372, eff. 7-29-10; 96-1504, eff. 1-27-11.) |
Section 50. The Emergency Medical Services (EMS) Systems |
Act is amended by changing Section 3.86 as follows: |
(210 ILCS 50/3.86) |
Sec. 3.86. Stretcher van providers. |
(a) In this Section, "stretcher van provider" means an |
entity licensed by the Department to provide non-emergency |
transportation of passengers on a stretcher in compliance with |
this Act or the rules adopted by the Department pursuant to |
this Act, utilizing stretcher vans. |
(b) The Department has the authority and responsibility to |
do the following: |
(1) Require all stretcher van providers, both publicly |
and privately owned, to be licensed by the Department. |
(2) Establish licensing and safety standards and |
requirements for stretcher van providers, through rules |
|
adopted pursuant to this Act, including but not limited to: |
(A) Vehicle design, specification, operation, and |
maintenance standards. |
(B) Safety equipment requirements and standards. |
(C) Staffing requirements. |
(D) Annual license renewal. |
(3) License all stretcher van providers that have met |
the Department's requirements for licensure. |
(4) Annually inspect all licensed stretcher van |
providers, and relicense providers that have met the |
Department's requirements for license renewal. |
(5) Suspend, revoke, refuse to issue, or refuse to |
renew the license of any stretcher van provider, or that |
portion of a license pertaining to a specific vehicle |
operated by a provider, after an opportunity for a hearing, |
when findings show that the provider or one or more of its |
vehicles has failed to comply with the standards and |
requirements of this Act or the rules adopted by the |
Department pursuant to this Act. |
(6) Issue an emergency suspension order for any |
provider or vehicle licensed under this Act when the |
Director or his or her designee has determined that an |
immediate or serious danger to the public health, safety, |
and welfare exists. Suspension or revocation proceedings |
that offer an opportunity for a hearing shall be promptly |
initiated after the emergency suspension order has been |
|
issued. |
(7) Prohibit any stretcher van provider from |
advertising, identifying its vehicles, or disseminating |
information in a false or misleading manner concerning the |
provider's type and level of vehicles, location, response |
times, level of personnel, licensure status, or EMS System |
participation. |
(8) Charge each stretcher van provider a fee, to be |
submitted with each application for licensure and license |
renewal. |
(c) A stretcher van provider may provide transport of a |
passenger on a stretcher, provided the passenger meets all of |
the following requirements: |
(1) (Blank). He or she needs no medical equipment, |
except self-administered medications. |
(2) He or she needs no medical monitoring or clinical |
observation medical observation . |
(3) He or she needs routine transportation to or from a |
medical appointment or service if the passenger is |
convalescent or otherwise bed-confined and does not |
require clinical observation medical monitoring , aid, |
care, or treatment during transport. |
(d) A stretcher van provider may not transport a passenger |
who meets any of the following conditions: |
(1) He or she is being transported to a hospital for |
emergency medical treatment. He or she is currently |
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admitted to a hospital or is being transported to a |
hospital for admission or emergency treatment. |
(2) He or she is experiencing an emergency medical |
condition or needs active medical monitoring, including |
isolation precautions, supplemental oxygen that is not |
self-administered, continuous airway management, |
suctioning during transport, or the administration of |
intravenous fluids during transport. He or she is acutely |
ill, wounded, or medically unstable as determined by a |
licensed physician. |
(3) He or she is experiencing an emergency medical |
condition, an acute medical condition, an exacerbation of a |
chronic medical condition, or a sudden illness or injury. |
(4) He or she was administered a medication that might |
prevent the passenger from caring for himself or herself. |
(5) He or she was moved from one environment where |
24-hour medical monitoring or medical observation will |
take place by certified or licensed nursing personnel to |
another such environment. Such environments shall include, |
but not be limited to, hospitals licensed under the |
Hospital Licensing Act or operated under the University of |
Illinois Hospital Act, and nursing facilities licensed |
under the Nursing Home Care Act. |
(e) The Stretcher Van Licensure Fund is created as a |
special fund within the State treasury. All fees received by |
the Department in connection with the licensure of stretcher |
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van providers under this Section shall be deposited into the |
fund. Moneys in the fund shall be subject to appropriation to |
the Department for use in implementing this Section.
|
(Source: P.A. 96-702, eff. 8-25-09; 96-1469, eff. 1-1-11.) |
Section 53. The Long Term Acute Care Hospital Quality |
Improvement Transfer Program Act is amended by changing |
Sections 35, 40, and 45 and by adding Section 55 as follows: |
(210 ILCS 155/35)
|
Sec. 35. LTAC supplemental per diem rate. |
(a) The Department must pay an LTAC supplemental per diem |
rate calculated under this Section to LTAC hospitals that meet |
the requirements of Section 15 of this Act for patients: |
(1) who upon admission to the LTAC hospital meet LTAC |
hospital criteria; and |
(2) whose care is primarily paid for by the Department |
under Title XIX of the Social Security Act or whose care is |
primarily paid for by the Department after the patient has |
exhausted his or her benefits under Medicare. |
(b) The Department must not pay the LTAC supplemental per |
diem rate calculated under this Section if any of the following |
conditions are met: |
(1) the LTAC hospital no longer meets the requirements |
under Section 15 of this Act or terminates the agreement |
specified under Section 15 of this Act; |
|
(2) the patient does not meet the LTAC hospital |
criteria upon admission; or |
(3) the patient's care is primarily paid for by |
Medicare and the patient has not exhausted his or her |
Medicare benefits, resulting in the Department becoming |
the primary payer. |
(c) The Department may adjust the LTAC supplemental per |
diem rate calculated under this Section based only on the |
conditions and requirements described under Section 40 and |
Section 45 of this Act. |
(d) The LTAC supplemental per diem rate shall be calculated |
using the LTAC hospital's inflated cost per diem, defined in |
subsection (f) of this Section, and subtracting the following: |
(1) The LTAC hospital's Medicaid per diem inpatient |
rate as calculated under 89 Ill. Adm. Code 148.270(c)(4). |
(2) The LTAC hospital's disproportionate share (DSH) |
rate as calculated under 89 Ill. Adm. Code 148.120. |
(3) The LTAC hospital's Medicaid Percentage Adjustment |
(MPA) rate as calculated under 89 Ill. Adm. Code 148.122. |
(4) The LTAC hospital's Medicaid High Volume |
Adjustment (MHVA) rate as calculated under 89 Ill. Adm. |
Code 148.290(d). |
(e) LTAC supplemental per diem rates are effective July 1, |
2012 shall be the amount in effect as of October 1, 2010. No |
new hospital may qualify for the program after the effective |
date of this amendatory Act of the 97th General Assembly for 12 |
|
months beginning on October 1 of each year and must be updated |
every 12 months . |
(f) For the purposes of this Section, "inflated cost per |
diem" means the quotient resulting from dividing the hospital's |
inpatient Medicaid costs by the hospital's Medicaid inpatient |
days and inflating it to the most current period using |
methodologies consistent with the calculation of the rates |
described in paragraphs (2), (3), and (4) of subsection (d). |
The data is obtained from the LTAC hospital's most recent cost |
report submitted to the Department as mandated under 89 Ill. |
Adm. Code 148.210.
|
(g) 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 Act or the Illinois |
Public Aid Code to reduce any rate of reimbursement for |
services or other payments in accordance with Section 5-5e of |
the Illinois Public Aid Code. |
(Source: P.A. 96-1130, eff. 7-20-10.) |
(210 ILCS 155/40)
|
Sec. 40. Rate adjustments for quality measures. |
(a) The Department may adjust the LTAC supplemental per |
diem rate calculated under Section 35 of this Act based on the |
requirements of this Section. |
(b) After the first year of operation of the Program |
established by this Act, the Department may reduce the LTAC |
|
supplemental per diem rate calculated under Section 35 of this |
Act by no more than 5% for an LTAC hospital that does not meet |
benchmarks or targets set by the Department under paragraph (2) |
of subsection (b) of Section 50. |
(c) After the first year of operation of the Program |
established by this Act, the Department may increase the LTAC |
supplemental per diem rate calculated under Section 35 of this |
Act by no more than 5% for an LTAC hospital that exceeds the |
benchmarks or targets set by the Department under paragraph (2) |
of subsection (a) of Section 50. |
(d) If an LTAC hospital misses a majority of the benchmarks |
for quality measures for 3 consecutive years, the Department |
may reduce the LTAC supplemental per diem rate calculated under |
Section 35 of this Act to zero. |
(e) An LTAC hospital whose rate is reduced under subsection |
(d) of this Section may have the LTAC supplemental per diem |
rate calculated under Section 35 of this Act reinstated once |
the LTAC hospital achieves the necessary benchmarks or targets. |
(f) The Department may apply the reduction described in |
subsection (d) of this Section after one year instead of 3 to |
an LTAC hospital that has had its rate previously reduced under |
subsection (d) of this Section and later has had it reinstated |
under subsection (e) of this Section. |
(g) The rate adjustments described in this Section shall be |
determined and applied only at the beginning of each rate year.
|
(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 Act or the Illinois |
Public Aid Code to reduce any rate of reimbursement for |
services or other payments in accordance with Section 5-5e of |
the Illinois Public Aid Code. |
(Source: P.A. 96-1130, eff. 7-20-10.) |
(210 ILCS 155/45)
|
Sec. 45. Program evaluation. |
(a) By After the Program completes the 3rd full year of |
operation on September 30, 2012 2013 , the Department must |
complete an evaluation of the Program to determine the actual |
savings or costs generated by the Program, both on an aggregate |
basis and on an LTAC hospital-specific basis. The evaluation |
must be conducted in each subsequent year. |
(b) The Department shall consult with and qualified LTAC |
hospitals to must determine the appropriate methodology to |
accurately calculate the Program's savings and costs. The |
calculation shall take into consideration, but shall not be |
limited to, the length of stay in an acute care hospital prior |
to transfer, the length of stay in the LTAC taking into account |
the acuity of the patient at the time of the LTAC admission, |
and admissions to the LTAC from settings other than an STAC |
hospital. |
(c) The evaluation must also determine the effects the |
Program has had in improving patient satisfaction and health |
|
outcomes. |
(d) If the evaluation indicates that the Program generates |
a net cost to the Department, the Department may prospectively |
adjust an individual hospital's LTAC supplemental per diem rate |
under Section 35 of this Act to establish cost neutrality. The |
rate adjustments applied under this subsection (d) do not need |
to be applied uniformly to all qualified LTAC hospitals as long |
as the adjustments are based on data from the evaluation on |
hospital-specific information. Cost neutrality under this |
Section means that the cost to the Department resulting from |
the LTAC supplemental per diem rate must not exceed the savings |
generated from transferring the patient from a STAC hospital. |
(e) The rate adjustment described in subsection (d) of this |
Section, if necessary, shall be applied to the LTAC |
supplemental per diem rate for the rate year beginning October |
1, 2014. The Department may apply this rate adjustment in |
subsequent rate years if the conditions under subsection (d) of |
this Section are met. The Department must apply the rate |
adjustment to an individual LTAC hospital's LTAC supplemental |
per diem rate only in years when the Program evaluation |
indicates a net cost for the Department. |
(f) The Department may establish a shared savings program |
for qualified LTAC hospitals. The rate adjustments described in |
this Section shall be determined and applied only at the |
beginning of each rate year.
|
(Source: P.A. 96-1130, eff. 7-20-10.) |
|
(210 ILCS 155/55 new) |
Sec. 55. Demonstration care coordination program for |
post-acute care. |
(a) The Department may develop a demonstration care |
coordination program for LTAC hospital appropriate patients |
with the goal of improving the continuum of care for patients |
who have been discharged from an LTAC hospital. |
(b) The program shall require risk-sharing and quality |
targets. |
Section 65. The Children's Health Insurance Program Act is |
amended by changing Sections 25 and 40 as follows:
|
(215 ILCS 106/25)
|
Sec. 25. Health benefits for children.
|
(a) The Department shall, subject to appropriation, |
provide health
benefits coverage to eligible children by:
|
(1) Subsidizing the cost of privately sponsored health |
insurance,
including employer based health insurance, to |
assist families to take
advantage of available privately |
sponsored health insurance for their
eligible children; |
and
|
(2) Purchasing or providing health care benefits for |
eligible
children. The health benefits provided under this |
subdivision (a)(2) shall,
subject to appropriation and |
|
without regard to any applicable cost sharing
under Section |
30, be identical to the benefits provided for children |
under the
State's approved plan under Title XIX of the |
Social Security Act. Providers
under this subdivision |
(a)(2) shall be subject to approval by the
Department to |
provide health care under the Illinois Public Aid Code and
|
shall be reimbursed at the same rate as providers under the |
State's approved
plan under Title XIX of the Social |
Security Act. In addition, providers may
retain |
co-payments when determined appropriate by the Department.
|
(b) The subsidization provided pursuant to subdivision |
(a)(1) shall be
credited to the family of the eligible child.
|
(c) The Department is prohibited from denying coverage to a |
child who is
enrolled in a privately sponsored health insurance |
plan pursuant to subdivision
(a)(1) because the plan does not |
meet federal benchmarking standards
or cost sharing and |
contribution requirements.
To be eligible for inclusion in the |
Program, the plan shall contain
comprehensive major medical |
coverage which shall consist of physician and
hospital |
inpatient services.
The Department is prohibited from denying |
coverage to a child who is enrolled
in a privately sponsored |
health insurance plan pursuant to subdivision (a)(1)
because |
the plan offers benefits in addition to physician and hospital
|
inpatient services.
|
(d) The total dollar amount of subsidizing coverage per |
child per month
pursuant to subdivision (a)(1) shall be equal |
|
to the average dollar payments,
less premiums incurred, per |
child per month pursuant to subdivision (a)(2).
The Department |
shall set this amount prospectively based upon the prior fiscal
|
year's experience adjusted for incurred but not reported claims |
and estimated
increases or decreases in the cost of medical |
care. Payments obligated before
July 1, 1999, will be computed |
using State Fiscal Year 1996 payments for
children eligible for |
Medical Assistance and income assistance under the Aid to
|
Families with Dependent Children Program, with appropriate |
adjustments for cost
and utilization changes through January 1, |
1999. The Department is
prohibited from providing a subsidy |
pursuant to subdivision (a)(1) that is more
than the |
individual's monthly portion of the premium.
|
(e) An eligible child may obtain immediate coverage under |
this Program
only once during a medical visit. If coverage |
lapses, re-enrollment shall be
completed in advance of the next |
covered medical visit and the first month's
required premium |
shall be paid in advance of any covered medical visit.
|
(f) In order to accelerate and facilitate the development |
of networks to
deliver services to children in areas outside |
counties with populations
in
excess of 3,000,000, in the event |
less than 25% of the eligible
children in a county or |
contiguous counties has enrolled with a Health
Maintenance |
Organization pursuant to Section 5-11 of the Illinois Public |
Aid
Code, the Department may develop and implement |
demonstration projects to create
alternative networks designed |
|
to enhance enrollment and participation in the
program. The |
Department shall prescribe by rule the criteria, standards, and
|
procedures for effecting demonstration projects under this |
Section.
|
(g) 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 Act or the Illinois |
Public Aid Code to reduce any rate of reimbursement for |
services or other payments in accordance with Section 5-5e of |
the Illinois Public Aid Code. |
(Source: P.A. 90-736, eff. 8-12-98 .)
|
(215 ILCS 106/40)
|
Sec. 40. Waivers. (a) The Department shall request any |
necessary waivers of federal
requirements in order to allow |
receipt of federal funding . for:
|
(1) the coverage of families with eligible children |
under this Act; and
|
(2) the coverage of
children who would otherwise be |
eligible under this Act, but who have health
insurance.
|
(b) The failure of the responsible federal agency to |
approve a
waiver for children who would otherwise be eligible |
under this Act but who have
health insurance shall not prevent |
the implementation of any Section of this
Act provided that |
there are sufficient appropriated funds.
|
(c) Eligibility of a person under an approved waiver due to |
|
the
relationship with a child pursuant to Article V of the |
Illinois Public Aid
Code or this Act shall be limited to such a |
person whose countable income is
determined by the Department |
to be at or below such income eligibility
standard as the |
Department by rule shall establish. The income level
|
established by the Department shall not be below 90% of the |
federal
poverty
level. Such persons who are determined to be |
eligible must reapply, or
otherwise establish eligibility, at |
least annually. An eligible person shall
be required, as |
determined by the Department by rule, to report promptly those
|
changes in income and other circumstances that affect |
eligibility. The
eligibility of a person may be
redetermined |
based on the information reported or may be terminated based on
|
the failure to report or failure to report accurately. A person |
may also be
held liable to the Department for any payments made |
by the Department on such
person's behalf that were |
inappropriate. An applicant shall be provided with
notice of |
these obligations.
|
(Source: P.A. 96-328, eff. 8-11-09.)
|
Section 70. The Covering ALL KIDS Health Insurance Act is |
amended by changing Sections 30 and 35 as follows: |
(215 ILCS 170/30) |
(Section scheduled to be repealed on July 1, 2016)
|
Sec. 30. Program outreach and marketing. The Department may |
|
provide grants to application agents and other community-based |
organizations to educate the public about the availability of |
the Program. The Department shall adopt rules regarding |
performance standards and outcomes measures expected of |
organizations that are awarded grants under this Section, |
including penalties for nonperformance of contract standards.
|
The Department shall annually publish electronically on a |
State website and in no less than 2 newspapers in the State the |
premiums or other cost sharing requirements of the Program.
|
(Source: P.A. 94-693, eff. 7-1-06; 95-985, eff. 6-1-09 .) |
(215 ILCS 170/35) |
(Section scheduled to be repealed on July 1, 2016)
|
Sec. 35. Health care benefits for children. |
(a) The Department shall purchase or provide health care |
benefits for eligible children that are identical to the |
benefits provided for children under the Illinois Children's |
Health Insurance Program Act, except for non-emergency |
transportation.
|
(b) As an alternative to the benefits set forth in |
subsection (a), and when cost-effective, the Department may |
offer families subsidies toward the cost of privately sponsored |
health insurance, including employer-sponsored health |
insurance.
|
(c) Notwithstanding clause (i) of subdivision (a)(3) of |
Section 20, the Department may consider offering, as an |
|
alternative to the benefits set forth in subsection (a), |
partial coverage to children who are enrolled in a |
high-deductible private health insurance plan.
|
(d) Notwithstanding clause (i) of subdivision (a)(3) of |
Section 20, the Department may consider offering, as an |
alternative to the benefits set forth in subsection (a), a |
limited package of benefits to children in families who have |
private or employer-sponsored health insurance that does not |
cover certain benefits such as dental or vision benefits.
|
(e) The content and availability of benefits described in |
subsections (b), (c), and (d), and the terms of eligibility for |
those benefits, shall be at the Department's discretion and the |
Department's determination of efficacy and cost-effectiveness |
as a means of promoting retention of private or |
employer-sponsored health insurance.
|
(f) 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 Act or the Illinois |
Public Aid Code to reduce any rate of reimbursement for |
services or other payments in accordance with Section 5-5e of |
the Illinois Public Aid Code. |
(Source: P.A. 94-693, eff. 7-1-06 .) |
Section 75. The Illinois Public Aid Code is amended by |
changing Sections 3-1.2, 5-2, 5-4, 5-4.1, 5-4.2, 5-5, 5-5.02, |
5-5.05, 5-5.2, 5-5.3, 5-5.4, 5-5.4e, 5-5.5, 5-5.8b, 5-5.12, |
|
5-5.17, 5-5.20, 5-5.23, 5-5.24, 5-5.25, 5-16.7, 5-16.7a, |
5-16.8, 5-16.9, 5-17, 5-19, 5-24, 5-30, 5A-1, 5A-2, 5A-3, 5A-4, |
5A-5, 5A-6, 5A-8, 5A-10, 5A-12.2, 5A-14, 6-11, 11-13, 11-26, |
12-4.25, 12-4.38, 12-4.39, 12-10.5, 12-13.1, 14-8, and 15-1 and |
by adding Sections 5-2b, 5-2.1d, 5-5e, 5-5e.1, 5-5f, 5A-15, |
11-5.2, 11-5.3, and 14-11 as follows:
|
(305 ILCS 5/3-1.2) (from Ch. 23, par. 3-1.2)
|
Sec. 3-1.2. 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
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. 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). 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.
|
In determining the resources of an individual or any |
dependents, the
Department shall exclude from consideration |
the value of funeral and burial
spaces, grave markers and other |
funeral and burial merchandise, 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) . |
Prepaid funeral or burial contracts are exempt to the |
following extent:
|
(1) Funds in a revocable prepaid funeral or burial |
contract are exempt up to $1,500, except that any portion |
of a contract that clearly represents the purchase of |
burial space, as that term is defined for purposes of the |
Supplemental Security Income program, is exempt regardless |
of value. |
(2) Funds in an irrevocable prepaid funeral or burial |
contract are exempt up to $5,874, except that any portion |
of a contract that clearly represents the purchase of |
burial space, as that term is defined for purposes of the |
Supplemental Security Income program, is exempt regardless |
of value. This amount shall be adjusted annually for any |
increase in the Consumer Price Index. The amount exempted |
shall be limited to the price of the funeral goods and |
services to be provided upon death. The contract must |
provide a complete description of the funeral goods and |
services to be provided and the price thereof. Any amount |
|
in the contract not so specified shall be treated as a |
transfer of assets for less than fair market value. |
(3) A prepaid, guaranteed-price funeral or burial |
contract, funded by an irrevocable assignment of a person's |
life insurance policy to a trust, is exempt. The amount |
exempted shall be limited to the amount of the insurance |
benefit designated for the cost of the funeral goods and |
services to be provided upon the person's death. The |
contract must provide a complete description of the funeral |
goods and services to be provided and the price thereof. |
Any amount in the contract not so specified shall be |
treated as a transfer of assets for less than fair market |
value. The trust must include a statement that, upon the |
death of the person, the State will receive all amounts |
remaining in the trust, including any remaining payable |
proceeds under the insurance policy up to an amount equal |
to the total medical assistance paid on behalf of the |
person. The trust is responsible for ensuring that the |
provider of funeral services under the contract receives |
the proceeds of the policy when it provides the funeral |
goods and services specified under the contract. The |
irrevocable assignment of ownership of the insurance |
policy must be acknowledged by the insurance company. |
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. Such 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. |
|
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.
|
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. 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 and Pharmaceutical Assistance 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, 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.
|
(Source: P.A. 91-676, eff. 12-23-99.)
|
(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:
|
1. Recipients of basic maintenance grants under |
Articles III and IV.
|
2. Persons otherwise eligible for basic maintenance |
under Articles
III and IV, excluding any eligibility |
requirements that are inconsistent with any federal law or |
federal regulation, as interpreted by the U.S. Department |
of Health and Human Services, but who fail to qualify |
thereunder on the basis of need or who qualify but are not |
receiving basic maintenance under Article IV, and
who have |
insufficient income and resources to meet the costs of
|
necessary medical care, including but not limited to the |
following:
|
|
(a) All persons otherwise eligible for basic |
maintenance under Article
III but who fail to qualify |
under that Article on the basis of need and who
meet |
either of the following requirements:
|
(i) their income, as determined by the |
Illinois Department in
accordance with any federal |
requirements, is equal to or less than 70% in
|
fiscal year 2001, equal to or less than 85% in |
fiscal year 2002 and until
a date to be determined |
by the Department by rule, and equal to or less
|
than 100% beginning on the date determined by the |
Department by rule, of the nonfarm income official |
poverty
line, as defined by the federal Office of |
Management and Budget and revised
annually in |
accordance with Section 673(2) of the Omnibus |
Budget Reconciliation
Act of 1981, applicable to |
families of the same size; or
|
(ii) their income, after the deduction of |
costs incurred for medical
care and for other types |
of remedial care, is equal to or less than 70% in
|
fiscal year 2001, equal to or less than 85% in |
fiscal year 2002 and until
a date to be determined |
by the Department by rule, and equal to or less
|
than 100% beginning on the date determined by the |
Department by rule, of the nonfarm income official |
poverty
line, as defined in item (i) of this |
|
subparagraph (a).
|
(b) All persons who, excluding any eligibility |
requirements that are inconsistent with any federal |
law or federal regulation, as interpreted by the U.S. |
Department of Health and Human Services, would be |
determined eligible for such basic
maintenance under |
Article IV by disregarding the maximum earned income
|
permitted by federal law.
|
3. Persons who would otherwise qualify for Aid to the |
Medically
Indigent under Article VII.
|
4. Persons not eligible under any of the preceding |
paragraphs who fall
sick, are injured, or die, not having |
sufficient money, property or other
resources to meet the |
costs of necessary medical care or funeral and burial
|
expenses.
|
5.(a) Women during pregnancy, after the fact
of |
pregnancy has been determined by medical diagnosis, and |
during the
60-day period beginning on the last day of the |
pregnancy, together with
their infants and children born |
after September 30, 1983,
whose income and
resources are |
insufficient to meet the costs of necessary medical care to
|
the maximum extent possible under Title XIX of the
Federal |
Social Security Act.
|
(b) The Illinois Department and the Governor shall |
provide a plan for
coverage of the persons eligible under |
paragraph 5(a) by April 1, 1990. Such
plan shall provide |
|
ambulatory prenatal care to pregnant women during a
|
presumptive eligibility period and establish an income |
eligibility standard
that is equal to 133%
of the nonfarm |
income official poverty line, as defined by
the federal |
Office of Management and Budget and revised annually in
|
accordance with Section 673(2) of the Omnibus Budget |
Reconciliation Act of
1981, applicable to families of the |
same size, provided that costs incurred
for medical care |
are not taken into account in determining such income
|
eligibility.
|
(c) The Illinois Department may conduct a |
demonstration in at least one
county that will provide |
medical assistance to pregnant women, together
with their |
infants and children up to one year of age,
where the |
income
eligibility standard is set up to 185% of the |
nonfarm income official
poverty line, as defined by the |
federal Office of Management and Budget.
The Illinois |
Department shall seek and obtain necessary authorization
|
provided under federal law to implement such a |
demonstration. Such
demonstration may establish resource |
standards that are not more
restrictive than those |
established under Article IV of this Code.
|
6. Persons under the age of 18 who fail to qualify as |
dependent under
Article IV and who have insufficient income |
and resources to meet the costs
of necessary medical care |
to the maximum extent permitted under Title XIX
of the |
|
Federal Social Security Act.
|
7. (Blank). Persons who are under 21 years of age and |
would
qualify as
disabled as defined under the Federal |
Supplemental Security Income Program,
provided medical |
service for such persons would be eligible for Federal
|
Financial Participation, and provided the Illinois |
Department determines that:
|
(a) the person requires a level of care provided by |
a hospital, skilled
nursing facility, or intermediate |
care facility, as determined by a physician
licensed to |
practice medicine in all its branches;
|
(b) it is appropriate to provide such care outside |
of an institution, as
determined by a physician |
licensed to practice medicine in all its branches;
|
(c) the estimated amount which would be expended |
for care outside the
institution is not greater than |
the estimated amount which would be
expended in an |
institution.
|
8. Persons who become ineligible for basic maintenance |
assistance
under Article IV of this Code in programs |
administered by the Illinois
Department due to employment |
earnings and persons in
assistance units comprised of |
adults and children who become ineligible for
basic |
maintenance assistance under Article VI of this Code due to
|
employment earnings. The plan for coverage for this class |
of persons shall:
|
|
(a) extend the medical assistance coverage for up |
to 12 months following
termination of basic |
maintenance assistance; and
|
(b) offer persons who have initially received 6 |
months of the
coverage provided in paragraph (a) above, |
the option of receiving an
additional 6 months of |
coverage, subject to the following:
|
(i) such coverage shall be pursuant to |
provisions of the federal
Social Security Act;
|
(ii) such coverage shall include all services |
covered while the person
was eligible for basic |
maintenance assistance;
|
(iii) no premium shall be charged for such |
coverage; and
|
(iv) such coverage shall be suspended in the |
event of a person's
failure without good cause to |
file in a timely fashion reports required for
this |
coverage under the Social Security Act and |
coverage shall be reinstated
upon the filing of |
such reports if the person remains otherwise |
eligible.
|
9. Persons with acquired immunodeficiency syndrome |
(AIDS) or with
AIDS-related conditions with respect to whom |
there has been a determination
that but for home or |
community-based services such individuals would
require |
the level of care provided in an inpatient hospital, |
|
skilled
nursing facility or intermediate care facility the |
cost of which is
reimbursed under this Article. Assistance |
shall be provided to such
persons to the maximum extent |
permitted under Title
XIX of the Federal Social Security |
Act.
|
10. Participants in the long-term care insurance |
partnership program
established under the Illinois |
Long-Term Care Partnership Program Act who meet the
|
qualifications for protection of resources described in |
Section 15 of that
Act.
|
11. Persons with disabilities who are employed and |
eligible for Medicaid,
pursuant to Section |
1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, |
subject to federal approval, persons with a medically |
improved disability who are employed and eligible for |
Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of |
the Social Security Act, as
provided by the Illinois |
Department by rule. In establishing eligibility standards |
under this paragraph 11, the Department shall, subject to |
federal approval: |
(a) set the income eligibility standard at not |
lower than 350% of the federal poverty level; |
(b) exempt retirement accounts that the person |
cannot access without penalty before the age
of 59 1/2, |
and medical savings accounts established pursuant to |
26 U.S.C. 220; |
|
(c) allow non-exempt assets up to $25,000 as to |
those assets accumulated during periods of eligibility |
under this paragraph 11; and
|
(d) continue to apply subparagraphs (b) and (c) in |
determining the eligibility of the person under this |
Article even if the person loses eligibility under this |
paragraph 11.
|
12. Subject to federal approval, persons who are |
eligible for medical
assistance coverage under applicable |
provisions of the federal Social Security
Act and the |
federal Breast and Cervical Cancer Prevention and |
Treatment Act of
2000. Those eligible persons are defined |
to include, but not be limited to,
the following persons:
|
(1) persons who have been screened for breast or |
cervical cancer under
the U.S. Centers for Disease |
Control and Prevention Breast and Cervical Cancer
|
Program established under Title XV of the federal |
Public Health Services Act in
accordance with the |
requirements of Section 1504 of that Act as |
administered by
the Illinois Department of Public |
Health; and
|
(2) persons whose screenings under the above |
program were funded in whole
or in part by funds |
appropriated to the Illinois Department of Public |
Health
for breast or cervical cancer screening.
|
"Medical assistance" under this paragraph 12 shall be |
|
identical to the benefits
provided under the State's |
approved plan under Title XIX of the Social Security
Act. |
The Department must request federal approval of the |
coverage under this
paragraph 12 within 30 days after the |
effective date of this amendatory Act of
the 92nd General |
Assembly.
|
In addition to the persons who are eligible for medical |
assistance pursuant to subparagraphs (1) and (2) of this |
paragraph 12, and to be paid from funds appropriated to the |
Department for its medical programs, any uninsured person |
as defined by the Department in rules residing in Illinois |
who is younger than 65 years of age, who has been screened |
for breast and cervical cancer in accordance with standards |
and procedures adopted by the Department of Public Health |
for screening, and who is referred to the Department by the |
Department of Public Health as being in need of treatment |
for breast or cervical cancer is eligible for medical |
assistance benefits that are consistent with the benefits |
provided to those persons described in subparagraphs (1) |
and (2). Medical assistance coverage for the persons who |
are eligible under the preceding sentence is not dependent |
on federal approval, but federal moneys may be used to pay |
for services provided under that coverage upon federal |
approval. |
13. Subject to appropriation and to federal approval, |
persons living with HIV/AIDS who are not otherwise eligible |
|
under this Article and who qualify for services covered |
under Section 5-5.04 as provided by the Illinois Department |
by rule.
|
14. Subject to the availability of funds for this |
purpose, the Department may provide coverage under this |
Article to persons who reside in Illinois who are not |
eligible under any of the preceding paragraphs and who meet |
the income guidelines of paragraph 2(a) of this Section and |
(i) have an application for asylum pending before the |
federal Department of Homeland Security or on appeal before |
a court of competent jurisdiction and are represented |
either by counsel or by an advocate accredited by the |
federal Department of Homeland Security and employed by a |
not-for-profit organization in regard to that application |
or appeal, or (ii) are receiving services through a |
federally funded torture treatment center. Medical |
coverage under this paragraph 14 may be provided for up to |
24 continuous months from the initial eligibility date so |
long as an individual continues to satisfy the criteria of |
this paragraph 14. If an individual has an appeal pending |
regarding an application for asylum before the Department |
of Homeland Security, eligibility under this paragraph 14 |
may be extended until a final decision is rendered on the |
appeal. The Department may adopt rules governing the |
implementation of this paragraph 14.
|
15. Family Care Eligibility. |
|
(a) On and after July 1, 2012 Through December 31, |
2013 , a caretaker relative who is 19 years of age or |
older when countable income is at or below 133% 185% of |
the Federal Poverty Level Guidelines, as published |
annually in the Federal Register, for the appropriate |
family size. Beginning January 1, 2014, a caretaker |
relative who is 19 years of age or older when countable |
income is at or below 133% of the Federal Poverty Level |
Guidelines, as published annually in the Federal |
Register, for the appropriate family size. A person may |
not spend down to become eligible under this paragraph |
15. |
(b) Eligibility shall be reviewed annually. |
(c) (Blank). Caretaker relatives enrolled under |
this paragraph 15 in families with countable income |
above 150% and at or below 185% of the Federal Poverty |
Level Guidelines shall be counted as family members and |
pay premiums as established under the Children's |
Health Insurance Program Act. |
(d) (Blank). Premiums shall be billed by and |
payable to the Department or its authorized agent, on a |
monthly basis. |
(e) (Blank). The premium due date is the last day |
of the month preceding the month of coverage. |
(f) (Blank). Individuals shall have a grace period |
through 60 days of coverage to pay the premium. |
|
(g) (Blank). Failure to pay the full monthly |
premium by the last day of the grace period shall |
result in termination of coverage. |
(h) (Blank). Partial premium payments shall not be |
refunded. |
(i) Following termination of an individual's |
coverage under this paragraph 15, the individual must |
be determined eligible before the person can be |
re-enrolled. following action is required before the |
individual can be re-enrolled: |
(1) A new application must be completed and the |
individual must be determined otherwise eligible. |
(2) There must be full payment of premiums due |
under this Code, the Children's Health Insurance |
Program Act, the Covering ALL KIDS Health |
Insurance Act, or any other healthcare program |
administered by the Department for periods in |
which a premium was owed and not paid for the |
individual. |
(3) The first month's premium must be paid if |
there was an unpaid premium on the date the |
individual's previous coverage was canceled. |
The Department is authorized to implement the |
provisions of this amendatory Act of the 95th General |
Assembly by adopting the medical assistance rules in effect |
as of October 1, 2007, at 89 Ill. Admin. Code 125, and at |
|
89 Ill. Admin. Code 120.32 along with only those changes |
necessary to conform to federal Medicaid requirements, |
federal laws, and federal regulations, including but not |
limited to Section 1931 of the Social Security Act (42 |
U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department |
of Health and Human Services, and the countable income |
eligibility standard authorized by this paragraph 15. The |
Department may not otherwise adopt any rule to implement |
this increase except as authorized by law, to meet the |
eligibility standards authorized by the federal government |
in the Medicaid State Plan or the Title XXI Plan, or to |
meet an order from the federal government or any court. |
16. Subject to appropriation, uninsured persons who |
are not otherwise eligible under this Section who have been |
certified and referred by the Department of Public Health |
as having been screened and found to need diagnostic |
evaluation or treatment, or both diagnostic evaluation and |
treatment, for prostate or testicular cancer. For the |
purposes of this paragraph 16, uninsured persons are those |
who do not have creditable coverage, as defined under the |
Health Insurance Portability and Accountability Act, or |
have otherwise exhausted any insurance benefits they may |
have had, for prostate or testicular cancer diagnostic |
evaluation or treatment, or both diagnostic evaluation and |
treatment.
To be eligible, a person must furnish a Social |
Security number.
A person's assets are exempt from |
|
consideration in determining eligibility under this |
paragraph 16.
Such persons shall be eligible for medical |
assistance under this paragraph 16 for so long as they need |
treatment for the cancer. A person shall be considered to |
need treatment if, in the opinion of the person's treating |
physician, the person requires therapy directed toward |
cure or palliation of prostate or testicular cancer, |
including recurrent metastatic cancer that is a known or |
presumed complication of prostate or testicular cancer and |
complications resulting from the treatment modalities |
themselves. Persons who require only routine monitoring |
services are not considered to need treatment.
"Medical |
assistance" under this paragraph 16 shall be identical to |
the benefits provided under the State's approved plan under |
Title XIX of the Social Security Act.
Notwithstanding any |
other provision of law, the Department (i) does not have a |
claim against the estate of a deceased recipient of |
services under this paragraph 16 and (ii) does not have a |
lien against any homestead property or other legal or |
equitable real property interest owned by a recipient of |
services under this paragraph 16. |
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 Illinois Department and the Governor shall provide a |
plan for
coverage of the persons eligible under paragraph 7 as |
soon as possible after
July 1, 1984.
|
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 Disabled Persons Property Tax |
Relief and Pharmaceutical
Assistance 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.
|
(Source: P.A. 96-20, eff. 6-30-09; 96-181, eff. 8-10-09; |
96-328, eff. 8-11-09; 96-567, eff. 1-1-10; 96-1000, eff. |
7-2-10; 96-1123, eff. 1-1-11; 96-1270, eff. 7-26-10; 97-48, |
eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, eff. 8-12-11; |
revised 10-4-11.)
|
(305 ILCS 5/5-2b new) |
Sec. 5-2b. Medically fragile and technology dependent |
children eligibility and program. Notwithstanding any other |
provision of law, 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, shall be limited to families with income up to 500% |
of the federal poverty level, 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. |
(305 ILCS 5/5-2.1d new) |
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.
|
(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 by the County Departments 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
Disabled Persons Property Tax Relief and |
Pharmaceutical Assistance 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 assets 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, the The community spouse
|
resource allowance shall be established and maintained at the |
higher of $109,560 or the minimum maximum level
permitted |
pursuant to Section 1924(f)(2) of the Social Security Act, as |
now
or hereafter amended, or an amount set after a fair |
hearing, whichever is
greater. The monthly maintenance |
allowance for the community spouse shall be
established and |
maintained at the higher of $2,739 per month or the minimum |
maximum level 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 |
institutionalized spouse, who has assigned his or her right |
of support from his or her spouse to the State, from the |
resources and income available to the community spouse. |
(ii) The Department may bring an action in the circuit |
court to establish support orders or itself establish |
|
administrative support orders by any means and procedures |
authorized in this Code, as applicable, except that the |
standard and regulations for determining ability to |
support in Section 10-3 shall not limit the amount of |
support that may be ordered. |
(iii) Proceedings may be initiated 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. Proceedings |
for the recovery of aid may be taken separately or they may |
be consolidated with actions to obtain support. Such |
proceedings may be brought in the name of the person or |
persons requiring support or may be brought in the name of |
the Department, as the case requires. |
(iv) The orders for the payment of moneys for the |
support of the person shall 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. In |
no event shall the orders reduce the community spouse |
resource allowance below the level established in |
subsection (a) of this Section or an amount set after a |
fair hearing, whichever is greater, or reduce the monthly |
maintenance allowance for the community spouse below the |
level permitted pursuant to subsection (a) of this Section. |
The Department of Human Services shall notify in writing |
|
each
institutionalized
spouse who is a recipient of medical |
assistance under this Article, and
each such person's community |
spouse, of the changes in treatment of income
and resources, |
including provisions for protecting income for a community
|
spouse and permitting the transfer of resources to a community |
spouse,
required by enactment of the federal Medicare |
Catastrophic Coverage Act of
1988 (Public Law 100-360). The |
notification shall be in language likely to
be easily |
understood by those persons. The Department of Human
Services |
also shall reassess the amount of medical assistance for which |
each
such recipient is eligible as a result of the enactment of |
that federal Act,
whether or not a recipient requests such a |
reassessment.
|
(Source: P.A. 95-331, eff. 8-21-07.)
|
(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 fee |
as a co-payment for services.
Co-payments shall be maximized to |
the extent permitted by federal law , except that the Department |
shall impose a co-pay of $2 on generic drugs . Provided, |
however, that any such rule must provide that 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. In the event the State plan |
amendment is rejected, co-payments may not exceed $3 for brand |
name drugs, $1 for other pharmacy
services other than for |
generic drugs, and $2 for physician services, dental
services, |
optical services and supplies, chiropractic services, podiatry
|
services, and encounter rate clinic services. There shall be no |
co-payment for
generic drugs. 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. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11.)
|
(305 ILCS 5/5-4.2) (from Ch. 23, par. 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, 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. |
(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.
|
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 |
established within 12 months after the effective date of this |
amendatory Act of the 97th General Assembly 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. |
(g) Whenever a patient covered by a medical assistance |
program under this Code or by another medical program |
administered by the Department is being discharged from a |
facility, a physician discharge order as described in this |
Section shall be required for each patient whose discharge |
requires medically supervised ground ambulance services. |
Facilities shall develop procedures for a physician with |
medical staff privileges to provide a written and signed |
|
physician discharge order. The physician discharge order shall |
specify the level of ground ambulance 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 order and the medical |
certification shall be completed prior to ordering an ambulance |
service and prior to patient discharge. |
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. |
(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. |
(Source: P.A. 97-584, eff. 8-26-11.)
|
(305 ILCS 5/5-5) (from Ch. 23, par. 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 women, 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, for |
children and adults; (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; and (17)
any other medical care, and any other type of |
remedial care recognized
under the laws of this State, but not |
including abortions, or induced
miscarriages or premature |
births, unless, in the opinion of a physician,
such procedures |
are necessary for the preservation of the life of the
woman |
seeking such treatment, or except an induced premature birth
|
intended to produce a live viable child and such procedure is |
necessary
for the health of the mother or her unborn child. The |
Illinois Department,
by rule, shall prohibit any physician from |
providing medical assistance
to anyone eligible therefor under |
this Code where such physician has been
found guilty of |
performing an abortion procedure in a wilful and wanton
manner |
upon a woman who was not pregnant at the time such abortion
|
procedure was performed. 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, 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.
|
On and after July 1, 2012, the The Department of Healthcare |
and Family Services may shall 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 |
supervision of a dentist; and
|
(2) eyeglasses prescribed by a physician skilled in the |
diseases of the
eye, or by an optometrist, whichever the |
person may select.
|
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. |
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 women |
35 years of age or older who are eligible
for medical |
assistance under this Article, as follows: |
(A) A baseline
mammogram for women 35 to 39 years of |
age.
|
(B) An annual mammogram for women 40 years of age or |
older. |
(C) A mammogram at the age and intervals considered |
|
medically necessary by the woman's health care provider for |
women under 40 years of age and having a family history of |
breast cancer, prior personal history of breast cancer, |
positive genetic testing, or other risk factors. |
(D) A comprehensive ultrasound screening of an entire |
breast or breasts if a mammogram demonstrates |
heterogeneous or dense breast tissue, when medically |
necessary as determined by a physician licensed to practice |
medicine in all of its branches. |
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, "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.
|
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. |
The Department shall convene an expert panel including |
representatives of hospitals, free-standing mammography |
|
facilities, and doctors, including radiologists, to establish |
quality standards. |
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. |
The Department shall establish a methodology to remind |
women 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 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. 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. |
Any medical or health care provider shall immediately |
recommend, to
any pregnant woman who is being provided prenatal |
services and is suspected
of drug abuse or is addicted as |
defined in the Alcoholism and Other Drug Abuse
and Dependency |
Act, referral to a local substance abuse treatment provider
|
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 women
under this Code shall receive information from |
the Department on the
availability of services under the Drug |
Free Families with a Future or any
comparable program providing |
case management services for addicted women,
including |
information on appropriate referrals for other social services
|
that may be needed by addicted women 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
her 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.
|
Notwithstanding any other provision of law, a health care |
provider under the medical assistance program may elect, in |
lieu of receiving direct payment for services provided under |
that program, to participate in the State Employees Deferred |
Compensation Plan adopted under Article 24 of the Illinois |
Pension Code. A health care provider who elects to participate |
in the plan does not have a cause of action against the State |
for any damages allegedly suffered by the provider as a result |
of any delay by the State in crediting the amount of any |
contribution to the provider's plan account. |
|
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 |
providing certain
services, which shall be determined by |
the Illinois Department, to persons
in areas covered by the |
Partnership may receive an additional surcharge
for such |
services.
|
(2) The Department may elect to consider and negotiate |
financial
incentives to encourage the development of |
|
Partnerships and the efficient
delivery of medical care.
|
(3) Persons receiving medical services through |
Partnerships may receive
medical and case management |
services above the level usually offered
through the |
medical assistance program.
|
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 the effective date of
this |
amendatory Act of 1984, 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.
|
The rules and regulations of the Illinois Department shall |
require
that a written statement including the required opinion |
of a physician
shall accompany any claim for reimbursement for |
abortions, or induced
miscarriages or premature births. This |
statement shall indicate what
procedures were used in providing |
such medical services.
|
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 that provides non-emergency medical |
transportation,
defined by the Department by rule,
shall be
|
subject to a provisional period and shall be conditional for |
one year 180 days . During the period of conditional enrollment |
that time , the Department of Healthcare and Family Services 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 That |
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 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 |
process by the Illinois Department, the 180-day period |
shall not begin until the date on the written notice from |
the Illinois Department that the provider enrollment is |
complete. |
(2) In the case of errors attributable to the Illinois |
Department or any of its claims processing intermediaries |
which result in an inability to receive, process, or |
adjudicate a claim, the 180-day period shall not begin |
until the provider has been notified of the error. |
(3) In the case of a provider for whom the Illinois |
Department initiates the monthly billing process. |
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, admission |
documents shall be submitted within 30 days of an admission to |
the facility 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. 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- 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 without
medical |
authorization ; 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 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.
|
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. 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 |
medical services by
public aid recipients;
|
(b) actual statistics and trends in the provision of |
the various medical
services by medical vendors;
|
(c) current rate structures and proposed changes in |
those rate structures
for the various medical vendors; and
|
(d) efforts at utilization review and control by the |
Illinois Department.
|
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 filing of one copy of the
report with the |
Speaker, one copy with the Minority Leader and one copy
with |
the Clerk of the House of Representatives, one copy with the |
President,
one copy with the Minority Leader and one copy with |
the Secretary of the
Senate, one copy with the Legislative |
Research Unit, and 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 shall be deemed sufficient to comply with this |
Section.
|
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. |
(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926, |
eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638, |
eff. 1-1-12.)
|
(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 |
applicable, for
inpatient hospital discharges occurring, |
on or after July 1, 1992 and on
or before September 30, |
1992, the Illinois Department shall reimburse
hospitals |
for inpatient services under the reimbursement |
methodologies in
effect for each hospital, and at the |
|
inpatient payment rate calculated for
each hospital, as of |
June 30, 1992. For purposes of this paragraph,
|
"reimbursement methodologies" means all reimbursement |
methodologies that
pertain to the provision of inpatient |
hospital services, including, but not
limited to, any |
adjustments for disproportionate share, targeted access,
|
critical care access and uncompensated care, as defined by |
the Illinois
Department on June 30, 1992.
|
(2) For the purpose of calculating the inpatient |
payment rate for each
hospital eligible to receive |
quarterly adjustment payments for targeted
access and |
critical care, as defined by the Illinois Department on |
June 30,
1992, the adjustment payment for the period July |
1, 1992 through September
30, 1992, shall be 25% of the |
annual adjustment payments calculated for
each eligible |
hospital, as of June 30, 1992. The Illinois Department |
shall
determine by rule the adjustment payments for |
targeted access and critical
care beginning October 1, |
1992.
|
(3) For the purpose of calculating the inpatient |
payment rate for each
hospital eligible to receive |
quarterly adjustment payments for
uncompensated care, as |
defined by the Illinois Department on June 30, 1992,
the |
adjustment payment for the period August 1, 1992 through |
September 30,
1992, shall be one-sixth of the total |
uncompensated care adjustment payments
calculated for each |
|
eligible hospital for the uncompensated care rate year,
as |
defined by the Illinois Department, ending on July 31, |
1992. The
Illinois Department shall determine by rule the |
adjustment payments for
uncompensated care beginning |
October 1, 1992.
|
(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 the |
federal Social
Security Act, as now or hereafter amended; |
or
|
(2) Illinois hospitals that have a Medicaid inpatient |
utilization
rate which is at least one-half a standard |
deviation above the mean Medicaid
inpatient utilization |
rate for all hospitals in Illinois receiving Medicaid
|
payments from the Illinois Department; or
|
(3) Illinois hospitals that on July 1, 1991 had a |
Medicaid inpatient
utilization rate, as defined in |
|
paragraph (h) of this Section,
that was at least the mean |
Medicaid inpatient utilization rate for all
hospitals in |
Illinois receiving Medicaid payments from the Illinois
|
Department and which were located in a planning area with |
one-third or
fewer excess beds as determined by the Health |
Facilities and Services Review Board, and that, as of June |
30, 1992, were located in a federally
designated Health |
Manpower Shortage Area; or
|
(4) Illinois hospitals that:
|
(A) have a Medicaid inpatient utilization rate |
that is at least
equal to the mean Medicaid inpatient |
utilization rate for all hospitals in
Illinois |
receiving Medicaid payments from the Department; and
|
(B) also have a Medicaid obstetrical inpatient |
utilization
rate that is at least one standard |
deviation above the mean Medicaid
obstetrical |
inpatient utilization rate for all hospitals in |
Illinois
receiving Medicaid payments from the |
Department for obstetrical services; or
|
(5) Any children's hospital, which means a hospital |
devoted exclusively
to caring for children. A hospital |
which includes a facility devoted
exclusively to caring for |
children shall be considered a
children's hospital to the |
degree that the hospital's Medicaid care is
provided to |
children
if either (i) the facility devoted exclusively to |
caring for children is
separately licensed as a hospital by |
|
a municipality prior to
September
30, 1998 or
(ii) the |
hospital has been
designated
by the State
as a Level III |
perinatal care facility, has a Medicaid Inpatient
|
Utilization rate
greater than 55% for the rate year 2003 |
disproportionate share determination,
and has more than |
10,000 qualified children days as defined by
the
Department |
in rulemaking.
|
(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 |
rate below the mean
shall receive a per day adjustment |
payment equal to $25;
|
(2) hospitals with a Medicaid inpatient utilization |
rate
that is equal to or greater than the mean Medicaid |
inpatient utilization rate
but less than one standard |
deviation above the mean Medicaid inpatient
utilization |
rate shall receive a per day adjustment payment
equal to |
the sum of $25 plus $1 for each one percent that the |
hospital's
Medicaid inpatient utilization rate exceeds the |
mean Medicaid inpatient
utilization rate;
|
(3) hospitals with a Medicaid inpatient utilization |
rate that is equal
to or greater than one standard |
deviation above the mean Medicaid inpatient
utilization |
rate but less than 1.5 standard deviations above the mean |
Medicaid
inpatient utilization rate shall receive a per day |
|
adjustment payment equal to
the sum of $40 plus $7 for each |
one percent that the hospital's Medicaid
inpatient |
utilization rate exceeds one standard deviation above the |
mean
Medicaid inpatient utilization rate; and
|
(4) hospitals with a Medicaid inpatient utilization |
rate that is equal
to or greater than 1.5 standard |
deviations above the mean Medicaid inpatient
utilization |
rate shall receive a per day adjustment payment equal to |
the sum of
$90 plus $2 for each one percent that the |
hospital's Medicaid inpatient
utilization rate exceeds 1.5 |
standard deviations above the mean Medicaid
inpatient |
utilization rate.
|
(d) Supplemental adjustment payments. In addition to the |
adjustment
payments described in paragraph (c), hospitals as |
defined in clauses
(1) through (5) 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 |
|
fraction, the numerator
of which is the number of a |
hospital's inpatient days provided in a given
12-month |
period to patients who, for such days, were eligible for |
Medicaid
under Title XIX of the federal Social Security |
Act, and the denominator of
which is the total number of |
the hospital's inpatient days in that same period.
|
(2) "Mean Medicaid inpatient utilization rate" means |
the total number
of Medicaid inpatient days provided by all |
Illinois Medicaid-participating
hospitals divided by the |
total number of inpatient days provided by those same
|
hospitals.
|
(3) "Medicaid obstetrical inpatient utilization rate" |
means the
ratio of Medicaid obstetrical inpatient days to |
total Medicaid inpatient
days for all Illinois hospitals |
receiving Medicaid payments from the
Illinois Department.
|
(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. |
(Source: P.A. 96-31, eff. 6-30-09.)
|
(305 ILCS 5/5-5.05) |
Sec. 5-5.05. Hospitals; psychiatric services. |
(a) On and after July 1, 2008, the inpatient, per diem rate |
to be paid to a hospital for inpatient psychiatric services |
shall be $363.77. |
(b) For purposes of this Section, "hospital" means the |
following: |
(1) Advocate Christ Hospital, Oak Lawn, Illinois. |
(2) Barnes-Jewish Hospital, St. Louis, Missouri. |
(3) BroMenn Healthcare, Bloomington, Illinois. |
(4) Jackson Park Hospital, Chicago, Illinois. |
(5) Katherine Shaw Bethea Hospital, Dixon, Illinois. |
(6) Lawrence County Memorial Hospital, Lawrenceville, |
Illinois. |
(7) Advocate Lutheran General Hospital, Park Ridge, |
Illinois. |
(8) Mercy Hospital and Medical Center, Chicago, |
Illinois. |
(9) Methodist Medical Center of Illinois, Peoria, |
|
Illinois. |
(10) Provena United Samaritans Medical Center, |
Danville, Illinois. |
(11) Rockford Memorial Hospital, Rockford, Illinois. |
(12) Sarah Bush Lincoln Health Center, Mattoon, |
Illinois. |
(13) Provena Covenant Medical Center, Urbana, |
Illinois. |
(14) Rush-Presbyterian-St. Luke's Medical Center, |
Chicago, Illinois. |
(15) Mt. Sinai Hospital, Chicago, Illinois. |
(16) Gateway Regional Medical Center, Granite City, |
Illinois. |
(17) St. Mary of Nazareth Hospital, Chicago, Illinois. |
(18) Provena St. Mary's Hospital, Kankakee, Illinois. |
(19) St. Mary's Hospital, Decatur, Illinois. |
(20) Memorial Hospital, Belleville, Illinois. |
(21) Swedish Covenant Hospital, Chicago, Illinois. |
(22) Trinity Medical Center, Rock Island, Illinois. |
(23) St. Elizabeth Hospital, Chicago, Illinois. |
(24) Richland Memorial Hospital, Olney, Illinois. |
(25) St. Elizabeth's Hospital, Belleville, Illinois. |
(26) Samaritan Health System, Clinton, Iowa. |
(27) St. John's Hospital, Springfield, Illinois. |
(28) St. Mary's Hospital, Centralia, Illinois. |
(29) Loretto Hospital, Chicago, Illinois. |
|
(30) Kenneth Hall Regional Hospital, East St. Louis, |
Illinois. |
(31) Hinsdale Hospital, Hinsdale, Illinois. |
(32) Pekin Hospital, Pekin, Illinois. |
(33) University of Chicago Medical Center, Chicago, |
Illinois. |
(34) St. Anthony's Health Center, Alton, Illinois. |
(35) OSF St. Francis Medical Center, Peoria, Illinois. |
(36) Memorial Medical Center, Springfield, Illinois. |
(37) A hospital with a distinct part unit for |
psychiatric services that begins operating on or after July |
1, 2008. |
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. |
(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) This Section shall not be in effect during any period |
of time that the State has in place a fully operational |
hospital assessment plan that has been approved by the Centers |
for Medicare and Medicaid Services of the U.S. Department of |
Health and Human Services.
|
(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. 95-1013, eff. 12-15-08.)
|
(305 ILCS 5/5-5.2) (from Ch. 23, par. 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) Notwithstanding any other provisions of this Code, |
beginning July 1, 2012 the methodologies for reimbursement of |
nursing facility 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 |
Resource Utilization Groups (RUGs) has been fully |
operationalized, which shall take effect for services provided |
on or after January 1, 2014. State fiscal years 2012 and |
thereafter. The Department of Healthcare and Family Services |
shall, effective July 1, 2012, implement an evidence-based |
payment methodology for the reimbursement of nursing facility |
services. The methodology shall continue to take into |
|
consideration the needs of individual residents, as assessed |
and reported by the most current version of the nursing |
facility Resident Assessment Instrument, adopted and in use by |
the federal government. |
(d) A new nursing services reimbursement methodology |
utilizing RUGs IV 48 grouper model shall be established and may |
include an Illinois-specific default group, as needed. The new |
RUGs-based nursing services reimbursement methodology shall be |
resident-driven, facility-specific, and cost-based. Costs |
shall be annually rebased and case mix index quarterly updated. |
The methodology shall include regional wage adjustors based on |
the Health Service Areas (HSA) groupings in effect on April 30, |
2012. The Department shall assign a case mix index to each |
resident class based on the Centers for Medicare and Medicaid |
Services staff time measurement study utilizing an index |
maximization approach. |
(e) Notwithstanding any other provision of this Code, the |
Department shall by rule develop a reimbursement methodology |
reflective of the intensity of care and services requirements |
of low need residents in the lowest RUG IV groupers and |
corresponding regulations. |
(f) Notwithstanding any other provision of this Code, on |
and after July 1, 2012, reimbursement rates associated with the |
nursing or support components of the current nursing facility |
rate methodology shall not increase beyond the level effective |
May 1, 2011 until a new reimbursement system based on the RUGs |
|
IV 48 grouper model has been fully operationalized. |
(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) Individual nursing rates for residents classified |
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter |
ending March 31, 2012 shall be reduced by 10%; |
(2) Individual nursing rates for residents classified |
in all other RUG IV groups shall be reduced by 1.0%; |
(3) Facility rates for the capital and support |
components shall be reduced by 1.7%. |
(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 shall have the nursing, |
socio-developmental, capital, and support components of their |
reimbursement rate effective May 1, 2011 reduced in total by |
2.7%. |
(Source: P.A. 96-1530, eff. 2-16-11.)
|
(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. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
|
(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 and before
|
January 1, 2014 July 1, 2012 , 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
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 |
component rate per patient day under the new system than |
the facility
received
effective on the date immediately |
preceding the date that the Department
implements the new |
payment methodology, the nursing component rate per |
patient
day for the facility
shall be held at
the level in |
effect on the date immediately preceding the date that the
|
Department implements the new payment methodology until a |
higher nursing
component rate of
reimbursement is achieved |
by that
facility.
|
(B) For a facility that would receive a higher nursing |
|
component rate per
patient day under the payment |
methodology in effect on July 1, 2003 than the
facility |
received effective on the date immediately preceding the |
date that the
Department implements the new payment |
methodology, the nursing component rate
per patient day for |
the facility shall be adjusted.
|
(C) Notwithstanding paragraphs (A) and (B), the |
nursing component rate per
patient day for the facility |
shall be adjusted subject to appropriations
provided by the |
General Assembly.
|
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, |
$60,000,000. |
(ii) For rates taking effect January 1, 2008, |
$110,000,000. |
(iii) For rates taking effect January 1, 2009, |
$194,000,000. |
(iv) For rates taking effect April 1, 2011, or the |
first day of the month that begins at least 45 days after |
the effective date of this amendatory Act of the 96th |
General Assembly, $416,500,000 or an amount as may be |
necessary to complete the transition to the MDS methodology |
for the nursing component of the rate. Increased payments |
under this item (iv) 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. |
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 Facilities Act, 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 the |
effective date of this amendatory Act of the 96th General |
Assembly, 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 the effective date |
of this amendatory Act of the 95th General Assembly 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 $8,000,000 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, tracheotomy care,
bariatric care, complex |
wound 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. |
(5) Beginning January July 1, 2014 2012 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 bills payable for |
State fiscal years 2012 and thereafter . |
(6) 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. |
(Source: P.A. 96-45, eff. 7-15-09; 96-339, eff. 7-1-10; 96-959, |
eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1530, eff. 2-16-11; |
97-10, eff. 6-14-11; 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; |
97-584, eff. 8-26-11; revised 10-4-11.) |
(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.) |
(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 component |
being determined
by taking into account the actual costs to |
the facilities of these services
subject to cost ceilings |
to be defined in the Department's rules.
|
(2) Resident Services, with the cost of this component |
being
determined by taking into account the actual costs, |
needs and utilization
of these services, as derived from an |
assessment of the resident needs in
the nursing facilities.
|
(3) Ancillary Services, with the payment rate being |
developed for
each individual type of service. Payment |
shall be made only when
authorized under procedures |
developed by the Department of Healthcare and Family |
Services.
|
(4) Nurse's Aide Training, with the cost of this |
component being
determined by taking into account the |
actual cost to the facilities of
such training.
|
(5) Real Estate Taxes, with the cost of this component |
being
determined by taking into account the figures |
contained in the most
currently available cost reports |
(with no imposition of maximums) updated
to the midpoint of |
the current rate year for long term care services
rendered |
between July 1, 1984 and June 30, 1985, and with the cost |
of this
component being determined by taking into account |
the actual 1983 taxes for
which the nursing homes were |
assessed (with no imposition of maximums)
updated to the |
|
midpoint of the current rate year for long term care
|
services rendered between July 1, 1985 and June 30, 1986.
|
(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 |
incurred interest
rate and the current value of the |
investment, including land, utilizing
composite rates, or |
by utilizing such other reasonable cost related methods
|
determined by the Department. However, beginning with the |
rate
reimbursement period effective July 1, 1987, the |
Department shall be
prohibited from establishing, |
including, and implementing any depreciation
factor in |
calculating the capital cost element.
|
(2) Profit, with the actual amount being produced and |
accruing to
the providers in the form of a return on their |
total investment, on the
basis of their ability to |
economically and efficiently deliver a type
of service. The |
method of payment may assure the opportunity for a
profit, |
but shall not guarantee or establish a specific amount as a |
cost.
|
(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. |
(Source: P.A. 95-331, eff. 8-21-07; 96-1123, eff. 1-1-11; |
96-1530, eff. 2-16-11.)
|
(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. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
|
(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 not impose requirements for prior |
approval
based on a preferred drug list for anti-retroviral, |
anti-hemophilic factor
concentrates,
or
any atypical |
antipsychotics, conventional antipsychotics,
or |
anticonvulsants used for the treatment of serious mental
|
illnesses
until 30 days after it has conducted a study of the |
impact of such
requirements on patient care and submitted a |
report to the Speaker of the
House of Representatives and the |
President of the Senate. 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 MR/DD |
Community Care 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 MR/DD Community Care 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. |
(i) (Blank). The Department shall seek any necessary waiver |
from the federal government in order to establish a program |
limiting the pharmacies eligible to dispense specialty drugs |
and shall issue a Request for Proposals in order to maximize |
savings on these drugs. The Department shall by rule establish |
the drugs required to be dispensed in this program. |
(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, and anti-retroviral |
drugs. |
(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 Services Act shall enroll in that |
program. No entity participating in the federal Drug Pricing |
Program under Section 340B of the federal Public Health |
Services Act may exclude Medicaid from their participation in |
that program, although the Department may exclude entities |
defined in Section 1905(l)(2)(B) of the Social Security Act |
from this requirement. |
(Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10; |
96-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff. |
6-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; revised |
10-4-11.)
|
(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 intellectually disabled
residents of such |
facilities 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. 97-227, eff. 1-1-12.)
|
(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. 89-38, eff. 1-1-96.)
|
(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 Human 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.
|
(c) The Department of Healthcare and Family Services shall |
work jointly with 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. |
(Source: P.A. 95-331, eff. 8-21-07.)
|
(305 ILCS 5/5-5.24)
|
Sec. 5-5.24. Prenatal and perinatal care. 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 |
health. These services may include
comprehensive risk |
assessments for pregnant women, women with infants, and
|
infants, lactation counseling, nutrition counseling, |
childbirth support,
psychosocial counseling, treatment and |
prevention of periodontal disease, and
other support
services
|
|
that have been proven to improve birth 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. |
(Source: P.A. 95-331, eff. 8-21-07.)
|
(305 ILCS 5/5-5.25) |
Sec. 5-5.25. Access to psychiatric mental health services. |
|
The General Assembly finds that providing access to psychiatric |
mental health services in a timely manner will improve the |
quality of life for persons suffering from mental illness and |
will contain health care costs by avoiding the need for more |
costly inpatient hospitalization. The Department of Healthcare |
and Family Services shall reimburse psychiatrists and |
federally qualified health centers as defined in
Section |
1905(l)(2)(B) of the federal Social Security Act for mental |
health services provided by psychiatrists, as
authorized by |
Illinois law, to recipients via telepsychiatry. 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, and (ii) a |
method to reimburse providers for mental health services |
provided by telepsychiatry.
|
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. 95-16, eff. 7-18-07.) |
(305 ILCS 5/5-5e new) |
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 this amendatory Act of
the |
97th General Assembly. In addition, the Department shall do the |
following: |
(1) Delink the per diem rate paid for supportive living |
facility services from the per diem rate paid for nursing |
facility services, effective for services provided on or |
after May 1, 2011. |
(2) Cease payment for bed reserves in nursing |
facilities, specialized mental health rehabilitation |
facilities, and, except in the instance of residents who |
are under 21 years of age, intermediate care facilities for |
persons with developmental disabilities. |
(3) Cease payment of the $10 per day add-on payment to |
nursing facilities for certain residents with |
developmental disabilities. |
(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 |
services, or community health center services reimbursed |
through an encounter rate, and services provided under the |
|
Medicaid Rehabilitation Option of the Illinois Title XIX |
State Plan shall not be further reduced. |
(2) Rates or payments, or the portion thereof, paid to |
a provider that is operated by a unit of local government |
or State University that provides the non-federal share of |
such services shall not be further reduced. |
(3) Rates or payments for hospital services delivered |
by a hospital defined as a Safety-Net Hospital under |
Section 5-5e.1 of this Code shall not be further reduced. |
(4) Rates or payments for hospital services delivered |
by a Critical Access Hospital, which is an Illinois |
hospital designated as a critical care hospital by the |
Department of Public Health in accordance with 42 CFR 485, |
Subpart F, shall not be further reduced. |
(5) Rates or payments for Nursing Facility Services |
shall only be further adjusted pursuant to Section 5-5.2 of |
this Code. |
(6) Rates or payments for services delivered by long |
term care facilities licensed under the ID/DD Community |
Care Act and developmental training services shall not be |
further reduced. |
(7) Rates or payments for services provided under |
capitation rates shall be adjusted taking into |
consideration the rates reduction and covered services |
required by this amendatory Act of the 97th General |
Assembly. |
|
(8) For hospitals not previously described in this |
subsection, the rates or payments for hospital services |
shall be further reduced by 3.5%, except for payments |
authorized under Section 5A-12.4 of this Code. |
(9) For all other rates or payments for services |
delivered by providers not specifically referenced in |
paragraphs (1) through (8), rates or payments shall be |
further reduced by 2.7%. |
(c) Any assessment imposed by this Code shall continue and |
nothing in this Section shall be construed to cause it to |
cease. |
(305 ILCS 5/5-5e.1 new) |
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 a |
general acute care or pediatric hospital; and |
(2) is a disproportionate share hospital, as described |
in Section 1923 of the federal Social Security Act, as |
determined by the Department; and |
(3) meets one of the following: |
(A) has a MIUR of at least 40% and a charity |
percent of at least 4%; or |
(B) has a MIUR of at least 50%. |
(b) Definitions. As used in this Section: |
(1) "Charity percent" means the ratio of (i) the |
|
hospital's charity charges for services provided to |
individuals without health insurance or another source of |
third party coverage to (ii) the Illinois total hospital |
charges, each as reported on the hospital's OBRA form. |
(2) "MIUR" means Medicaid Inpatient Utilization Rate |
and is defined as a fraction, the numerator of which is the |
number of a hospital's inpatient days provided in the |
hospital's fiscal year ending 3 years prior to the rate |
year, to patients who, for such days, were eligible for |
Medicaid under Title XIX of the federal Social Security |
Act, 42 USC 1396a et seq., and the denominator of which is |
the total number of the hospital's inpatient days in that |
same period. |
(3) "OBRA form" means form HFS-3834, OBRA '93 data |
collection form, for the rate year. |
(4) "Rate year" means the 12-month period beginning on |
October 1. |
(c) For the 27-month period beginning July 1, 2012, a |
hospital that would have qualified for the rate year beginning |
October 1, 2011, 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. |
|
(305 ILCS 5/5-5f new) |
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 services shall no longer be a covered |
service available under this Code: group psychotherapy for |
residents of any facility licensed under the Nursing Home Care |
Act or the Specialized Mental Health Rehabilitation Act; and |
adult chiropractic services. |
(b) The Department shall place the following limitations on |
services: (i) the Department shall limit adult eyeglasses to |
one pair every 2 years; (ii) the Department shall set an annual |
limit of a maximum of 20 visits for each of the following |
services: adult speech, hearing, and language therapy |
services, adult occupational therapy services, and physical |
therapy services; (iii) the Department shall limit podiatry |
services to individuals with diabetes; (iv) the Department |
shall pay for caesarean sections at the normal vaginal delivery |
rate unless a caesarean section was medically necessary; (v) |
the Department shall limit adult dental services to |
emergencies; and (vi) effective July 1, 2012, the Department |
shall place limitations and require concurrent review on every |
inpatient detoxification stay to prevent repeat admissions to |
any hospital for detoxification within 60 days of a previous |
inpatient detoxification stay. The Department shall convene a |
|
workgroup of hospitals, substance abuse providers, care |
coordination entities, managed care plans, and other |
stakeholders to develop recommendations for quality standards, |
diversion to other settings, and admission criteria for |
patients who need inpatient detoxification. |
(c) The Department shall require prior approval of the |
following services: wheelchair repairs, regardless of the cost |
of the repairs, coronary artery bypass graft, and bariatric |
surgery consistent with Medicare standards concerning patient |
responsibility. The wholesale cost of power wheelchairs shall |
be actual acquisition cost including all discounts. |
(d) The Department shall establish benchmarks for |
hospitals to measure and align payments to reduce potentially |
preventable hospital readmissions, inpatient complications, |
and unnecessary emergency room visits. In doing so, the |
Department shall consider items, including, but not limited to, |
historic and current acuity of care and historic and current |
trends in readmission. The Department shall publish |
provider-specific historical readmission data and anticipated |
potentially preventable targets 60 days prior to the start of |
the program. In the instance of readmissions, the Department |
shall adopt policies and rates of reimbursement for services |
and other payments provided under this Code to ensure that, by |
June 30, 2013, expenditures to hospitals are reduced by, at a |
minimum, $40,000,000. |
(e) The Department shall establish utilization controls |
|
for the hospice program such that it shall not pay for other |
care services when an individual is in hospice. |
(f) For home health services, the Department shall require |
Medicare certification of providers participating in the |
program, implement the Medicare face-to-face encounter rule, |
and limit services to post-hospitalization. The Department |
shall require providers to implement auditable electronic |
service verification based on global positioning systems or |
other cost-effective technology. |
(g) For the Home Services Program operated by the |
Department of Human Services and the Community Care Program |
operated by the Department on Aging, the Department of Human |
Services, in cooperation with the Department on Aging, shall |
implement an electronic service verification based on global |
positioning systems or other cost-effective technology. |
(h) The Department shall not pay for hospital admissions |
when the claim indicates a hospital acquired condition that |
would cause Medicare to reduce its payment on the claim had the |
claim been submitted to Medicare, nor shall the Department pay |
for hospital admissions where a Medicare identified "never |
event" occurred. |
(i) The Department shall implement cost savings |
initiatives for advanced imaging services, cardiac imaging |
services, pain management services, and back surgery. Such |
initiatives shall be designed to achieve annual costs savings.
|
|
(305 ILCS 5/5-16.7)
|
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. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
|
(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. 93-981, eff. 8-23-04.)
|
|
(305 ILCS 5/5-16.8)
|
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, 356u, 356w, 356x, and 356z.6 of the |
Illinois
Insurance Code and (ii) be subject to the provisions |
of Sections 356z.19 and 364.01 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. 97-282, eff. 8-9-11.)
|
(305 ILCS 5/5-16.9)
|
Sec. 5-16.9. Woman's health care provider. 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. 92-370, eff. 8-15-01.)
|
(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 |
provided charitable care to
indigent patients, this |
burden is not equally borne by all hospitals operating
|
in this State. Some hospitals continue to provide |
significant amounts of care
to low-income persons |
while others provide very little such care; and
|
(B) That access to hospital care in this State by |
the indigent
citizens of Illinois would be seriously |
impaired by the closing of
hospitals that provide |
significant amounts of care to low-income persons.
|
(2) To help expand the availability of hospital care |
for all citizens
of this State, it is the policy of the |
State to implement programs that
more equitably distribute |
the burden of providing hospital care to
Illinois' |
low-income population and that improve access to health |
care
in Illinois.
|
(3) The Illinois Department may develop and implement a |
program that
lessens the burden of providing hospital care |
to Illinois' low-income
population, taking into account |
the costs that must be incurred by
hospitals providing |
|
significant amounts of care to low-income persons, and
may |
develop adjustments to increase rates to improve access to |
health care
in Illinois. The Illinois Department shall |
prescribe by rule the criteria,
standards and procedures |
for effecting such adjustments in the rates of
hospital |
payments for services provided to eligible low-income |
persons
(under Articles V, VI and VII of this Code) under |
this Article.
|
(b) The Illinois Department shall require hospitals |
certified to
participate in the federal Medicaid program to:
|
(1) provide equal access to available services to |
low-income persons
who are eligible for assistance under |
Articles V, VI and VII of this Code;
|
(2) provide data and reports on the provision of |
uncompensated care.
|
(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. 87-13; 87-838.)
|
|
(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 |
coverage for
periodic health, vision, hearing, and dental |
screenings for children
eligible for Healthy Kids services |
|
scheduled from a child's birth up until
the child turns 21 |
years. The Illinois Department shall pay for vision,
|
hearing, dental and health screening examinations for any |
child eligible
for Healthy Kids services by qualified |
providers at intervals established
by Department rules.
|
(2) The Illinois Department shall pay for an |
interperiodic health,
vision, hearing, or dental screening |
examination for any child eligible
for Healthy Kids |
services whenever an examination is:
|
(A) requested by a child's parent, guardian, or
|
custodian, or is determined to be necessary or |
appropriate by social
services, developmental, health, |
or educational personnel; or
|
(B) necessary for enrollment in school; or
|
(C) necessary for enrollment in a licensed day care |
program,
including Head Start; or
|
(D) necessary for placement in a licensed child |
welfare facility,
including a foster home, group home |
or child care institution; or
|
(E) necessary for attendance at a camping program; |
or
|
(F) necessary for participation in an organized |
athletic program; or
|
(G) necessary for enrollment in an early childhood |
education program
recognized by the Illinois State |
Board of Education; or
|
|
(H) necessary for participation in a Women, |
Infant, and Children
(WIC) program; or
|
(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 |
including:
|
(A) Development/Mental Health/Psychosocial |
Assessment; and
|
(B) Assessment of nutritional status including |
tests for iron
deficiency and anemia for children at |
the following ages: 9 months, 2
years, 8 years, and 18 |
years;
|
(2) Comprehensive unclothed physical exam;
|
(3) Appropriate immunizations at a minimum, as |
required by the
Secretary of the U.S. Department of Health |
and Human Services under
42 U.S.C. 1396d(r).
|
(4) Appropriate laboratory tests including blood lead |
levels
appropriate for age and risk factors.
|
(A) Anemia test.
|
(B) Sickle cell test.
|
(C) Tuberculin test at 12 months of age and every |
1-2 years
thereafter unless the treating health care |
professional determines that
testing is medically |
contraindicated.
|
|
(D) Other -- The Illinois Department shall insure |
that testing for
HIV, drug exposure, and sexually |
transmitted diseases is provided for as
clinically |
indicated.
|
(5) Health Education. The Illinois Department shall |
require providers
to provide anticipatory guidance as |
recommended by the American Academy of
Pediatrics.
|
(6) Vision Screening. The Illinois Department shall |
require providers
to provide vision screenings consistent |
with those set forth in the
Department of Public Health's |
Administrative Rules.
|
(7) Hearing Screening. The Illinois Department shall |
require providers
to provide hearing screenings consistent |
with those set forth in the
Department of Public Health's |
Administrative Rules.
|
(8) Dental Screening. The Illinois Department shall |
require
providers to provide dental screenings consistent |
with those set forth in the
Department of Public Health's |
Administrative Rules.
|
(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 |
eligible for Healthy
Kids services and the child's family |
about the benefits provided under the
Healthy Kids Program, |
including, but not limited to, the following: what
services |
are available under Healthy Kids, including discussion of |
the
periodicity schedules and immunization schedules, that |
services are
provided at no cost to eligible children, the |
benefits of preventive health
care, where the services are |
available, how to obtain them, and that
necessary |
transportation and scheduling assistance is available.
|
(2) The Illinois Department shall widely disseminate |
information
regarding the availability of the Healthy Kids |
Program throughout the State
by outreach activities which |
shall include, but not be limited to, (i) the
development |
of cooperation agreements with local school districts, |
public
health agencies, clinics, hospitals and other |
health care providers,
including developmental disability |
and mental health providers, and with
charities, to notify |
the constituents of each of the Program and assist
|
individuals, as feasible, with applying for the Program, |
(ii) using the
media for public service announcements and |
advertisements of the Program,
and (iii) developing |
posters advertising the Program for display in
hospital and |
clinic waiting rooms.
|
(3) The Illinois Department shall utilize accepted |
|
methods for
informing persons who are illiterate, blind, |
deaf, or cannot understand the
English language, including |
but not limited to public services announcements
and |
advertisements in the foreign language media of radio, |
television and
newspapers.
|
(4) The Illinois Department shall provide notice of the |
Healthy Kids
Program to every child eligible for Healthy |
Kids services and his or her
family at the following times:
|
(A) orally by the intake worker and in writing at |
the time of
application for Medical Assistance;
|
(B) at the time the applicant is informed that he |
or she is eligible
for Medical Assistance benefits; and
|
(C) at least 20 days before the date of any |
periodic health, vision,
hearing, and dental |
examination for any child eligible for Healthy Kids
|
services. Notice given under this subparagraph (C) |
must state that a
screening examination is due under |
the periodicity schedules and must
advise the eligible |
child and his or her family that the Illinois
|
Department will provide assistance in scheduling an |
appointment and
arranging medical transportation.
|
(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. |
(Source: P.A. 87-630; 87-895.)
|
(305 ILCS 5/5-24)
|
(Section scheduled to be repealed on January 1, 2014)
|
Sec. 5-24. Disease management programs and services for
|
chronic conditions; pilot project. |
(a) In this Section, "disease management programs and
|
services" means services administered to patients in order to |
improve
their overall health and to prevent clinical |
exacerbations and
complications, using cost-effective, |
evidence-based practice
guidelines and patient self-management |
strategies. Disease
management programs and services include |
all of the following:
|
(1) A population identification process.
|
(2) Evidence-based or consensus-based clinical |
practice
guidelines, risk identification, and matching of |
interventions with
clinical need.
|
(3) Patient self-management and disease education.
|
|
(4) Process and outcomes measurement, evaluation, |
management, and
reporting.
|
(b) Subject to appropriations, the Department of |
Healthcare and Family Services may
undertake a pilot project to |
study patient outcomes, for patients with chronic
diseases or |
patients at risk of low birth weight or premature birth, |
associated with the use of disease management programs and |
services
for chronic condition management. "Chronic diseases" |
include, but are not
limited to, diabetes, congestive heart |
failure, and chronic obstructive
pulmonary disease. Low birth |
weight and premature birth include all medical and other |
conditions that lead to poor birth outcomes or problematic |
pregnancies.
|
(c) The disease management programs and services pilot
|
project shall examine whether chronic disease management |
programs and
services for patients with specific chronic |
conditions do any or all
of the following:
|
(1) Improve the patient's overall health in a more |
expeditious
manner.
|
(2) Lower costs in other aspects of the medical |
assistance program, such
as hospital admissions, days in |
skilled nursing homes, emergency room
visits, or more |
frequent physician office visits.
|
(d) In carrying out the pilot project, the Department of |
Healthcare and Family Services shall
examine all relevant |
scientific literature and shall consult with
health care |
|
practitioners including, but not limited to, physicians,
|
surgeons, registered pharmacists, and registered nurses.
|
(e) The Department of Healthcare and Family Services shall |
consult with medical experts,
disease advocacy groups, and |
academic institutions to develop criteria
to be used in |
selecting a vendor for the pilot project.
|
(f) The Department of Healthcare and Family Services may |
adopt rules to implement this
Section.
|
(g) This Section is repealed 10 years after the effective |
date of this
amendatory Act of the 93rd General Assembly.
|
(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. |
(Source: P.A. 95-331, eff. 8-21-07; 96-799, eff. 10-28-09.)
|
(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 the |
effective date of this amendatory Act of the 96th General |
Assembly. |
(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 this amendatory |
Act of the 96th General Assembly. 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 |
|
services administered to recipients of medical assistance |
under this Article to prevent exacerbations and |
complications using cost-effective, evidence-based |
practice guidelines and mental health management |
strategies. |
(2) The Department may utilize and expand upon existing |
contractual arrangements with integrated care plans under |
the Integrated Care Program for providing the coordinated |
care provisions of this Section. |
(3) Payment for such coordinated care shall be based on |
arrangements where the State pays for performance related |
to mental health outcomes 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 such as |
provider-based care coordination. |
(4) The Department shall examine whether chronic |
mental health management programs and services for |
recipients with specific chronic mental health conditions |
do any or all of the following: |
(A) Improve the patient's overall mental health in |
a more expeditious and cost-effective manner. |
(B) Lower costs in other aspects of the medical |
assistance program, such as hospital admissions, |
emergency room visits, or more frequent and |
inappropriate psychotropic drug use. |
|
(5) The Department shall work with the facilities and |
any integrated care plan participating in the program to |
identify and correct barriers to the successful |
implementation of this subsection (e) prior to and during |
the implementation to best facilitate the goals and |
objectives of this subsection (e). |
(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 the effective date of this amendatory Act of |
the 97th General Assembly 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 provide |
hospital services to enrollees of the care coordination |
program. |
(2) The hospital has not been offered a contract by a |
care coordination plan that pays at least as much as the |
Department would pay, on a fee-for-service basis, not |
|
including disproportionate share hospital adjustment |
payments or any other supplemental adjustment or add-on |
payment to the base fee-for-service rate. |
(Source: P.A. 96-1501, eff. 1-25-11.) |
(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:
|
"Adjusted gross hospital revenue" shall be determined |
separately for inpatient and outpatient services for each |
hospital conducted, operated or maintained by a hospital |
provider, and means the hospital provider's total gross |
revenues less: (i) gross revenue attributable to non-hospital |
based services including home dialysis services, durable |
medical equipment, ambulance services, outpatient clinics and |
any other non-hospital based services as determined by the |
Illinois Department by rule; and (ii) gross revenues |
attributable to the routine services provided to persons |
receiving skilled or intermediate long-term care services |
within the meaning of Title XVIII or XIX of the Social Security |
Act; and (iii) Medicare gross revenue (excluding the Medicare |
gross revenue attributable to clauses (i) and (ii) of this |
paragraph and the Medicare gross revenue attributable to the |
routine services provided to patients in a psychiatric |
hospital, a rehabilitation hospital, a distinct part |
psychiatric unit, a distinct part rehabilitation unit, or swing |
|
beds). Adjusted gross hospital revenue shall be determined |
using the most recent data available from each hospital's 2003 |
Medicare cost report as contained in the Healthcare Cost Report |
Information System file, for the quarter ending on December 31, |
2004, without regard to any subsequent adjustments or changes |
to such data. If a hospital's 2003 Medicare cost report is not |
contained in the Healthcare Cost Report Information System, the |
hospital provider shall furnish such cost report or the data |
necessary to determine its adjusted gross hospital revenue as |
required by rule by the Illinois Department.
|
"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. |
"Proration factor" means a fraction, the numerator of which |
is 53 and the denominator of which is 365.
|
(Source: P.A. 94-242, eff. 7-18-05; 95-859, eff. 8-19-08.)
|
(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2) |
(Section scheduled to be repealed on July 1, 2014) |
Sec. 5A-2. Assessment.
|
(a) Subject to Sections 5A-3 and 5A-10, an annual |
assessment on inpatient
services is imposed on
each
hospital
|
provider in an amount equal to the hospital's occupied bed days |
multiplied by $84.19 multiplied by the proration factor for |
State fiscal year 2004 and the hospital's occupied bed days |
multiplied by $84.19 for State fiscal year 2005.
|
For State fiscal years 2004 and 2005, the
Department of |
|
Healthcare and Family Services
shall use the number of occupied |
bed days as reported
by
each hospital on the Annual Survey of |
Hospitals conducted by the
Department of Public Health to |
calculate the hospital's annual assessment. If
the sum
of a |
hospital's occupied bed days is not reported on the Annual |
Survey of
Hospitals or if there are data errors in the reported |
sum of a hospital's occupied bed days as determined by the |
Department of Healthcare and Family Services (formerly |
Department of Public Aid), then the Department of Healthcare |
and Family Services may obtain the sum of occupied 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 |
Department of Healthcare and Family Services
or its duly |
authorized agents and
employees.
|
Subject to Sections 5A-3 and 5A-10, for the privilege of |
engaging in the occupation of hospital provider, beginning |
August 1, 2005, an annual assessment is imposed on each |
hospital provider for State fiscal years 2006, 2007, and 2008, |
in an amount equal to 2.5835% of the hospital provider's |
adjusted gross hospital revenue for inpatient services and |
2.5835% of the hospital provider's adjusted gross hospital |
revenue for outpatient services. If the hospital provider's |
adjusted gross hospital revenue is not available, then the |
Illinois Department may obtain the hospital provider's |
adjusted gross hospital 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 Illinois Department or its |
duly authorized agents and employees.
|
Subject to Sections 5A-3 and 5A-10, for State fiscal years |
2009 through 2014 and July 1, 2014 through December 31, 2014 , |
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. |
For State fiscal years 2009 through 2014 and after , 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. |
(b) (Blank).
|
|
(c) (Blank).
|
(d) Notwithstanding any of the other provisions of this |
Section, the Department is authorized , during this 94th General |
Assembly, 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. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
|
(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). For State fiscal years 2004 through 2014, a |
hospital provider, described in Section 1903(w)(3)(F) of the |
Social Security Act, whose hospital does not
charge for its |
services is exempt from the assessment imposed
by Section 5A-2, |
unless the exemption is adjudged to be unconstitutional or
|
otherwise invalid, in which case the hospital provider shall |
pay the assessment
imposed by Section 5A-2.
|
(b-15) (Blank). For State fiscal years 2004 and 2005, a |
|
hospital provider whose hospital is licensed by
the Department |
of Public Health as a psychiatric hospital is
exempt from the |
assessment imposed by Section 5A-2, unless the exemption is
|
adjudged to be unconstitutional or
otherwise invalid, in which |
case the hospital provider shall pay the assessment
imposed by |
Section 5A-2.
|
(b-20) (Blank). For State fiscal years 2004 and 2005, a |
hospital provider whose hospital is licensed by the Department |
of
Public Health as a rehabilitation hospital is exempt from |
the assessment
imposed by
Section 5A-2, unless the exemption is
|
adjudged to be unconstitutional or
otherwise invalid, in which |
case the hospital provider shall pay the assessment
imposed by |
Section 5A-2.
|
(b-25) (Blank). For State fiscal years 2004 and 2005, a |
hospital provider whose hospital (i) is not a psychiatric |
hospital,
rehabilitation hospital, or children's hospital and |
(ii) has an average length
of inpatient
stay greater than 25 |
days is exempt from the assessment imposed by Section
5A-2, |
unless the exemption is
adjudged to be unconstitutional or
|
otherwise invalid, in which case the hospital provider shall |
pay the assessment
imposed by Section 5A-2.
|
(c) (Blank).
|
(Source: P.A. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
|
(305 ILCS 5/5A-4) (from Ch. 23, par. 5A-4) |
Sec. 5A-4. Payment of assessment; penalty.
|
|
(a) The The annual assessment imposed by Section 5A-2 for |
State fiscal year
2004
shall be due
and payable on June 18 of
|
the
year.
The assessment imposed by Section 5A-2 for State |
fiscal year 2005
shall be
due and payable in quarterly |
installments, each equalling one-fourth of the
assessment for |
the year, on July 19, October 19, January 18, and April 19 of
|
the year. The assessment imposed by Section 5A-2 for State |
fiscal years 2006 through 2008 shall be due and payable in |
quarterly installments, each equaling one-fourth of the |
assessment for the year, on the fourteenth State business day |
of September, December, March, and May. Except as provided in |
subsection (a-5) of this Section, the assessment imposed by |
Section 5A-2 for State fiscal year 2009 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 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. : (i) the |
Department notifies the hospital provider, in writing,
that the |
payment methodologies to
hospitals
required under
Section |
5A-12, Section 5A-12.1, or Section 5A-12.2, whichever is |
applicable for that fiscal year, 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 has issued the payments |
required under Section 5A-12, Section 5A-12.1, or Section |
5A-12.2, whichever is applicable for that fiscal year.
Upon |
notification to the Department of approval of the payment |
methodologies required under Section 5A-12, Section 5A-12.1, |
or Section 5A-12.2, whichever is applicable for that fiscal |
year, and the waiver granted under 42 CFR 433.68, 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 of the payments required under Section 5A-12.1 or |
Section 5A-12.2, whichever is applicable for that fiscal year.
|
(a-5) The Illinois Department may, for the purpose of |
maximizing federal revenue, 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 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, by the total assessment for the State fiscal year |
imposed under 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. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08; |
|
96-821, eff. 11-20-09.) |
(305 ILCS 5/5A-5) (from Ch. 23, par. 5A-5) |
Sec. 5A-5. Notice; penalty; maintenance of records.
|
(a)
The Illinois Department of Healthcare and Family |
Services 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 Section 5A-12, |
Section 5A-12.1, or Section 5A-12.2, whichever is applicable |
for that fiscal year , 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 |
place
of business from which the provider engages in the |
occupation of hospital
provider in this State, and the name |
and address of each hospital
operated, conducted, or |
maintained by the provider in this State.
|
(3) The occupied bed days, occupied bed days less |
Medicare days, or adjusted gross hospital revenue of the
|
hospital
provider (whichever is applicable), the amount of
|
|
assessment imposed under Section 5A-2 for the State fiscal |
year
for which the notice is sent, and the amount of
each
|
installment to be paid during the State fiscal year.
|
(4) (Blank).
|
(5) Other reasonable information as determined by the |
Illinois
Department.
|
(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 2004 and 2005, in
the case of a hospital |
provider that did not conduct, operate, or
maintain a hospital |
throughout calendar year 2001, 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 State fiscal years 2006 through 2008, in |
the case of a hospital provider that did not conduct, operate, |
or maintain a hospital in 2003, the assessment for that State |
fiscal year shall be computed on the basis of hypothetical |
adjusted gross hospital revenue for the hospital's first full |
fiscal year as determined by the Illinois Department (which may |
be based on annualization of the provider's actual revenues for |
a portion of the year, or revenues of a comparable hospital for |
the year, including revenues realized by a prior provider of |
the same hospital during the year).
Notwithstanding any other |
provision in this Article, for State fiscal years 2009 through |
2015 2014 , 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.
|
|
(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. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08; |
96-1530, eff. 2-16-11.)
|
(305 ILCS 5/5A-6) (from Ch. 23, par. 5A-6)
|
Sec. 5A-6. Disposition of proceeds. The Illinois |
Department
shall deposit pay 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 under 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. 87-861.)
|
(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 under |
Articles V, V-A, VI,
and XIV of this Code, under the |
Children's Health Insurance Program Act, under the |
Covering ALL KIDS Health Insurance Act, and under the Long |
Term Acute Care Hospital Quality Improvement Transfer |
Program Act. Senior Citizens and Disabled Persons Property |
|
Tax Relief and Pharmaceutical Assistance Act.
|
(2) For the reimbursement of moneys collected by the
|
Illinois Department from hospitals or hospital providers |
through error or
mistake in performing the
activities |
authorized under this Article and Article V of this Code.
|
(3) For payment of administrative expenses incurred by |
the
Illinois Department or its agent in performing the |
activities
under authorized by this Code, the Children's |
Health Insurance Program Act, the Covering ALL KIDS Health |
Insurance Act, and the Long Term Acute Care Hospital |
Quality Improvement Transfer Program Act. Article.
|
(4) For payments of any amounts which are reimbursable |
to
the federal government for payments from this Fund which |
are
required to be paid by State warrant.
|
(5) For making transfers, as those transfers are |
authorized
in the proceedings authorizing debt under the |
Short Term Borrowing Act,
but transfers made under this |
paragraph (5) shall not exceed the
principal amount of debt |
issued in anticipation of the receipt by
the State of |
moneys to be deposited into the Fund.
|
(6) For making transfers to any other fund in the State |
treasury, but
transfers made under this paragraph (6) shall |
not exceed the amount transferred
previously from that |
other fund into the Hospital Provider Fund plus any |
interest that would have been earned by that fund on the |
monies that had been transferred .
|
|
(6.5) For making transfers to the Healthcare Provider |
Relief Fund, except that transfers made under this |
paragraph (6.5) shall not exceed $60,000,000 in the |
aggregate. |
(7) For making transfers not exceeding the following |
amounts, in each State fiscal year during which an |
assessment is imposed pursuant to Section 5A-2, to the |
following designated funds: |
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 days |
after the payments have been received pursuant to the schedule |
of payments provided in subsection (a) of Section 5A-4. For |
State fiscal years 2004 and 2005 for making transfers to the |
Health and Human Services
Medicaid Trust Fund, including 20% of |
the moneys received from
hospital providers under Section 5A-4 |
and transferred into the Hospital
Provider
Fund under Section |
5A-6. For State fiscal year 2006 for making transfers to the |
Health and Human Services Medicaid Trust Fund of up to |
$130,000,000 per year of the moneys received from hospital |
providers under Section 5A-4 and transferred into the Hospital |
Provider Fund under Section 5A-6. Transfers under this |
paragraph shall be made within 7
days after the payments have |
been received pursuant to the schedule of payments
provided in |
|
subsection (a) of Section 5A-4.
|
(7.5) (Blank). For State fiscal year 2007 for making
|
transfers of the moneys received from hospital providers |
under Section 5A-4 and transferred into the Hospital |
Provider Fund under Section 5A-6 to the designated funds |
not exceeding the following amounts
in that State fiscal |
year: |
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 |
days after the payments have been received pursuant to the |
schedule of payments provided in subsection (a) of Section |
5A-4.
|
(7.8) (Blank). For State fiscal year 2008, for making |
transfers of the moneys received from hospital providers |
under Section 5A-4 and transferred into the Hospital |
Provider Fund under Section 5A-6 to the designated funds |
not exceeding the following amounts in that State fiscal |
year: |
Health and Human Services |
Medicaid Trust Fund ..................$40,000,00 0 |
Long-Term Care Provider Fund ..............$60,000,000 |
General Revenue Fund ....................$160,000,000. |
Transfers under this paragraph shall be made within 7 |
|
days after the payments have been received pursuant to the |
schedule of payments provided in subsection (a) of Section |
5A-4. |
(7.9) (Blank). For State fiscal years 2009 through |
2014, for making transfers of the moneys received from |
hospital providers under Section 5A-4 and transferred into |
the Hospital Provider Fund under Section 5A-6 to the |
designated funds not exceeding the following amounts in |
that State fiscal year: |
Health and Human Services |
Medicaid Trust Fund ...................$20,000,000 |
Long Term Care Provider Fund ..............$30,000,000 |
General Revenue Fund .....................$80,000,000. |
Except as provided under this paragraph, transfers |
under this paragraph shall be made within 7 business days |
after the payments have been received pursuant to the |
schedule of payments provided in subsection (a) of Section |
5A-4. For State fiscal year 2009, transfers to the General |
Revenue Fund under this paragraph shall be made on or |
before June 30, 2009, as sufficient funds become available |
in the Hospital Provider Fund to both make the transfers |
and continue hospital payments. |
(8) For making refunds to hospital providers pursuant |
to Section 5A-10.
|
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
|
Department from the hospital provider assessment imposed |
by this
Article.
|
(2) All federal matching funds received by the Illinois
|
Department as a result of expenditures made by the Illinois
|
Department that are attributable to moneys deposited in the |
Fund.
|
(3) Any interest or penalty levied in conjunction with |
the
administration of this Article.
|
(4) Moneys transferred from another fund in the State |
treasury.
|
(5) All other moneys received for the Fund from any |
other
source, including interest earned thereon.
|
(d) (Blank).
|
(Source: P.A. 95-707, eff. 1-11-08; 95-859, eff. 8-19-08; 96-3, |
eff. 2-27-09; 96-45, eff. 7-15-09; 96-821, eff. 11-20-09; |
96-1530, eff. 2-16-11.)
|
(305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)
|
Sec. 5A-10. Applicability.
|
(a) 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 , 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 |
Article are not eligible for federal matching funds under |
Title XIX or XXI of the Social Security Act The sum of the |
appropriations for State fiscal years 2004 and 2005
from |
the
General Revenue Fund for hospital payments
under the |
medical assistance program is less than $4,500,000,000 or |
the appropriation for each of State fiscal years 2006, 2007 |
and 2008 from the General Revenue Fund for hospital |
payments under the medical assistance program is less than |
$2,500,000,000 increased annually to reflect any increase |
in the number of recipients, or the annual appropriation |
for State fiscal years 2009, 2010, 2011, 2013, and 2014, |
from the General Revenue Fund combined with the Hospital |
Provider Fund as authorized in Section 5A-8 for hospital |
payments under the medical assistance program, is less than |
the amount appropriated for State fiscal year 2009, |
adjusted annually to reflect any change in the number of |
recipients, excluding State fiscal year 2009 supplemental |
appropriations made necessary by the enactment of the |
American Recovery and Reinvestment Act of 2009 ; or
|
(2) For State fiscal years prior to State fiscal year |
2009, the Department of Healthcare and Family Services |
(formerly Department of Public Aid) makes changes in its |
|
rules
that
reduce the hospital inpatient or outpatient |
payment rates, including adjustment
payment rates, in |
effect on October 1, 2004, except for hospitals described |
in
subsection (b) of Section 5A-3 and except for changes in |
the methodology for calculating outlier payments to |
hospitals for exceptionally costly stays, so long as those |
changes do not reduce aggregate
expenditures below the |
amount expended in State fiscal year 2005 for such
|
services; or
|
(2) (2.1) For State fiscal years 2009 through 2014 and |
July 1, 2014 through December 31, 2014 , the
Department of |
Healthcare and Family Services adopts any administrative |
rule change to reduce payment rates or alters any payment |
methodology that reduces any payment rates made to |
operating hospitals under the approved Title XIX or Title |
XXI State plan in effect January 1, 2008 except for: |
(A) any changes for hospitals described in |
subsection (b) of Section 5A-3; or |
(B) any rates for payments made under this Article |
V-A; or |
(C) any changes proposed in State plan amendment |
transmittal numbers 08-01, 08-02, 08-04, 08-06, and |
08-07; or |
(D) in relation to any admissions on or after |
January 1, 2011, a modification in the methodology for |
calculating outlier payments to hospitals for |
|
exceptionally costly stays, for hospitals reimbursed |
under the diagnosis-related grouping methodology in |
effect on January 1, 2011 ; provided that the Department |
shall be limited to one such modification during the |
36-month period after the effective date of this |
amendatory Act of the 96th General Assembly; or |
(E) any changes affecting hospitals authorized by |
this amendatory Act of the 97th General Assembly. |
(3) The payments to hospitals required under Section |
5A-12 or Section 5A-12.2 are changed or
are
not eligible |
for federal matching funds under Title XIX or XXI of the |
Social
Security Act.
|
(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.
|
(Source: P.A. 96-8, eff. 4-28-09; 96-1530, eff. 2-16-11; 97-72, |
eff. 7-1-11; 97-74, eff. 6-30-11.)
|
|
(305 ILCS 5/5A-12.2) |
(Section scheduled to be repealed on July 1, 2014) |
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 |
services, the Department shall pay to each Illinois general |
acute care hospital an amount equal to 40% of the total |
base inpatient payments paid to the hospital for services |
provided in State fiscal year 2005. |
(2) In addition to rates paid for inpatient hospital |
services, the Department shall pay to each freestanding |
Illinois specialty care hospital as defined in 89 Ill. Adm. |
Code 149.50(c)(1), (2), or (4) an amount equal to 60% of |
the total base inpatient payments paid to the hospital for |
services provided in State fiscal year 2005. |
(3) In addition to rates paid for inpatient hospital |
services, the Department shall pay to each freestanding |
Illinois rehabilitation or psychiatric hospital an amount |
equal to $1,000 per Medicaid inpatient day multiplied by |
the increase in the hospital's Medicaid inpatient |
utilization ratio (determined using the positive |
percentage change from the rate year 2005 Medicaid |
inpatient utilization ratio to the rate year 2007 Medicaid |
inpatient utilization ratio, as calculated by the |
Department for the disproportionate share determination). |
(4) In addition to rates paid for inpatient hospital |
services, the Department shall pay to each Illinois |
children's hospital an amount equal to 20% of the total |
base inpatient payments paid to the hospital for services |
provided in State fiscal year 2005 and an additional amount |
|
equal to 20% of the base inpatient payments paid to the |
hospital for psychiatric services provided in State fiscal |
year 2005. |
(5) In addition to rates paid for inpatient hospital |
services, the Department shall pay to each Illinois |
hospital eligible for a pediatric inpatient adjustment |
payment under 89 Ill. Adm. Code 148.298, as in effect for |
State fiscal year 2007, a supplemental pediatric inpatient |
adjustment payment equal to: |
(i) For freestanding children's hospitals as |
defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5 |
multiplied by the hospital's pediatric inpatient |
adjustment payment required under 89 Ill. Adm. Code |
148.298, as in effect for State fiscal year 2008. |
(ii) For hospitals other than freestanding |
children's hospitals as defined in 89 Ill. Adm. Code |
149.50(c)(3)(B), 1.0 multiplied by the hospital's |
pediatric inpatient adjustment payment required under |
89 Ill. Adm. Code 148.298, as in effect for State |
fiscal year 2008. |
(c) Outpatient adjustment. |
(1) In addition to the rates paid for outpatient |
hospital services, the Department shall pay each Illinois |
hospital an amount equal to 2.2 multiplied by the |
hospital's ambulatory procedure listing payments for |
categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code |
|
148.140(b), for State fiscal year 2005. |
(2) In addition to the rates paid for outpatient |
hospital services, the Department shall pay each Illinois |
freestanding psychiatric hospital an amount equal to 3.25 |
multiplied by the hospital's ambulatory procedure listing |
payments for category 5b, as defined in 89 Ill. Adm. Code |
148.140(b)(1)(E), for State fiscal year 2005. |
(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 |
greater than the 85th percentile of hospital case mix |
indices, $350 for each Medicaid inpatient day of care |
provided during that period; and |
(2) For hospitals with a case mix index less than the |
85th percentile of hospital case mix indices, $100 for each |
Medicaid inpatient day of care provided during that period. |
(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 that |
|
has a Medicaid inpatient utilization rate of at least 10% |
and less than 36.94% and whose capital cost is less than |
the 60th percentile of the capital costs of all Illinois |
hospitals, the amount of such payment shall equal the |
hospital's Medicaid inpatient days multiplied by the |
difference between the capital costs at the 60th percentile |
of the capital costs of all Illinois hospitals and the |
hospital's capital costs. |
(2) For each Illinois general acute care hospital that |
has a Medicaid inpatient utilization rate of at least |
36.94% and whose capital cost is less than the 75th |
percentile of the capital costs of all Illinois hospitals, |
the amount of such payment shall equal the hospital's |
Medicaid inpatient days multiplied by the difference |
between the capital costs at the 75th percentile of the |
capital costs of all Illinois hospitals and the hospital's |
capital costs. |
(f) Obstetrical care adjustment. |
(1) In addition to rates paid for inpatient hospital |
services, the Department shall pay $1,500 for each Medicaid |
obstetrical day of care provided in State fiscal year 2005 |
by each Illinois rural hospital that had a Medicaid |
obstetrical percentage (Medicaid obstetrical days divided |
by Medicaid inpatient days) greater than 15% for State |
fiscal year 2005. |
(2) In addition to rates paid for inpatient hospital |
|
services, the Department shall pay $1,350 for each Medicaid |
obstetrical day of care provided in State fiscal year 2005 |
by each Illinois general acute care hospital that was |
designated a level III perinatal center as of December 31, |
2006, and that had a case mix index equal to or greater |
than the 45th percentile of the case mix indices for all |
level III perinatal centers. |
(3) In addition to rates paid for inpatient hospital |
services, the Department shall pay $900 for each Medicaid |
obstetrical day of care provided in State fiscal year 2005 |
by each Illinois general acute care hospital that was |
designated a level II or II+ perinatal center as of |
December 31, 2006, and that had a case mix index equal to |
or greater than the 35th percentile of the case mix indices |
for all level II and II+ perinatal centers. |
(g) Trauma adjustment. |
(1) In addition to rates paid for inpatient hospital |
services, the Department shall pay each Illinois general |
acute care hospital designated as a trauma center as of |
July 1, 2007, a payment equal to 3.75 multiplied by the |
hospital's State fiscal year 2005 Medicaid capital |
payments. |
(2) In addition to rates paid for inpatient hospital |
services, the Department shall pay $400 for each Medicaid |
acute inpatient day of care provided in State fiscal year |
2005 by each Illinois general acute care hospital that was |
|
designated a level II trauma center, as defined in 89 Ill. |
Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1, |
2007. |
(3) In addition to rates paid for inpatient hospital |
services, the Department shall pay $235 for each Illinois |
Medicaid acute inpatient day of care provided in State |
fiscal year 2005 by each level I pediatric trauma center |
located outside of Illinois that had more than 8,000 |
Illinois Medicaid inpatient days in State fiscal year 2005. |
(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 eligibility |
growth factor is greater than the mean, $450 multiplied by |
the eligibility growth factor for the county in which the |
hospital is located for each Medicaid inpatient day of care |
provided by the hospital during State fiscal year 2005. |
(2) For hospitals located in a county whose eligibility |
growth factor is less than or equal to the mean, $225 |
multiplied by the eligibility growth factor for the county |
in which the hospital is located for each Medicaid |
inpatient day of care provided by the hospital during State |
fiscal year 2005. |
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 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). For State fiscal years 2012 and 2013, the |
Department may make recommendations to the General Assembly |
regarding the use of more recent data for purposes of |
calculating the assessment authorized under Section 5A-2 and |
the payments authorized under this Section 5A-12.2. |
(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. |
(Source: P.A. 95-859, eff. 8-19-08; 96-821, eff. 11-20-09 .) |
(305 ILCS 5/5A-14) |
Sec. 5A-14. Repeal of assessments and disbursements. |
(a) Section 5A-2 is repealed on January 1, 2015 July 1, |
2014 . |
(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 is repealed on January 1, 2015 July 1, |
2014 . |
(e) Section 5A-12.3 is repealed on July 1, 2011. |
(Source: P.A. 95-859, eff. 8-19-08; 96-821, eff. 11-20-09; |
96-1530, eff. 2-16-11.) |
(305 ILCS 5/5A-15 new) |
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) the payments under this Article that exceed the |
applicable federal upper payment limit shall be reduced |
uniformly to the extent necessary to comply with the |
applicable federal upper payment limit; and |
|
(2) any assessment rate imposed under this Article |
shall be reduced such that the aggregate assessment is |
reduced by the same percentage reduction applied in |
paragraph (1); and |
(3) any transfers from the Hospital Provider Fund under |
Section 5A-8 shall be reduced by the same percentage |
reduction applied in paragraph (1). |
(b) Any payment reductions made under the authority granted |
in this Section are exempt from the requirements and actions |
under Section 5A-10.
|
(305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
|
Sec. 6-11. State funded 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) State funded General Assistance may shall consist of 2 |
separate
programs. One program shall be for adults with no |
|
children and shall be
known as State Transitional Assistance. |
The other program may shall be for
families with children and |
for pregnant women and shall be known as State
Family and |
Children Assistance.
|
(c) (1) To be eligible for State 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 |
age.
|
(2) The Illinois Department or the local governmental unit |
shall determine
whether individuals are chronically needy as |
follows:
|
(A) Individuals who have applied for Supplemental |
Security Income (SSI)
and are awaiting a decision on |
eligibility for SSI who are determined disabled
by
the |
Illinois Department using the SSI standard shall be |
considered chronically
needy, except that individuals |
whose disability is based solely on substance
addictions |
(drug abuse and alcoholism) and whose disability would |
cease were
their addictions to end shall be eligible only |
for medical assistance and shall
not be eligible for cash |
assistance under the State Transitional Assistance
|
program.
|
(B) (Blank). If an individual has been denied SSI due |
|
to a finding of "not
disabled" (either at the |
Administrative Law Judge level or above, or at a lower
|
level if that determination was not appealed), the Illinois |
Department shall
adopt that finding and the individual |
shall not be eligible for State
Transitional Assistance or |
any related medical benefits. Such an individual
may not be |
determined disabled by the Illinois Department for a period |
of 12
months, unless the individual shows that there has |
been a substantial change in
his or her medical condition |
or that there has been a substantial change in
other |
factors, such as age or work experience, that might change |
the
determination of disability.
|
(C) The unit of local government Illinois Department, |
by rule, may specify other categories of
individuals as |
chronically needy; nothing in this Section, however, shall |
be
deemed to require the inclusion of any specific category |
other than as
specified in paragraph paragraphs (A) and |
(B) .
|
(3) For individuals in State Transitional Assistance, |
medical assistance may
shall be provided by the unit of local |
government in an amount and nature determined by the unit of |
local government. Nothing Department
of Healthcare and Family |
Services by rule. The amount and nature of medical assistance |
provided
need not be the
same as that provided under paragraph |
(4) of subsection (d) of this Section,
and 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). The Illinois Department shall determine, by |
rule, those assistance
recipients under Article VI who shall be |
subject to employment, training, or
education programs |
including Earnfare, the content of those programs, and the
|
penalties for failure to cooperate in those programs.
|
(5) (Blank). The Illinois Department shall, by rule, |
establish further eligibility
requirements, including but not |
limited to residence, need, and the level of
payments.
|
(d) (1) To be eligible for State 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 |
school or the
equivalent level of vocational or technical |
training, and who may
reasonably be expected to complete |
the program before reaching age 19.
|
Those children shall be eligible for State Family and |
Children Assistance.
|
(2) The natural or adoptive parents of the child living in |
the same
household may be eligible for State Family and |
Children Assistance.
|
(3) A pregnant woman whose pregnancy has been verified |
|
shall be
eligible for income maintenance assistance under the |
State Family and
Children Assistance program.
|
(4) The amount and nature of medical assistance provided |
under the State
Family and Children Assistance program shall be |
determined by the unit of local government
Department of |
Healthcare and Family Services by rule . 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). The Illinois Department shall, by rule, |
establish further
eligibility requirements, including but not |
limited to residence, need, and
the level of payments.
|
(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). In order to qualify for State funding under |
this Section, a local
governmental unit shall be subject to the |
supervision and the rules and
regulations of the Illinois |
Department.
|
(g) (Blank). Notwithstanding any other provision in this |
Code, the Illinois
Department is authorized to reduce payment |
levels used to determine cash grants
provided to recipients of |
|
State Transitional Assistance at any time within a
Fiscal Year |
in order to ensure that cash benefits for State Transitional
|
Assistance do not exceed the amounts appropriated for those |
cash benefits.
Changes 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. This provision shall also be
applicable to any reduction |
in payment levels made upon implementation of this
amendatory |
Act of 1995.
|
(Source: P.A. 95-331, eff. 8-21-07.)
|
(305 ILCS 5/11-5.2 new) |
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 |
insurance payment information maintained by the Department |
of Employment Security. |
(3) Earned and unearned income, citizenship and death, |
and other relevant information maintained by the Social |
Security Administration. |
(4) Immigration status information maintained by the |
United States Citizenship and Immigration Services. |
(5) Wage reporting and similar information maintained |
by states contiguous to this State. |
(6) Employment information maintained by the |
Department of Employment Security in its New Hire Directory |
database. |
(7) Employment information maintained by the United |
States Department of Health and Human Services in its |
National Directory of New Hires database. |
(8) Veterans' benefits information maintained by the |
|
United States Department of Health and Human Services, in |
coordination with the Department of Health and Human |
Services and the Department of Veterans' Affairs, in the |
federal Public Assistance Reporting Information System |
(PARIS) database. |
(9) Residency information maintained by the Illinois |
Secretary of State. |
(10) A database which is substantially similar to or a |
successor of a database described in this Section that |
contains information relevant for verifying eligibility |
for medical assistance. |
(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) or (c) 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 (c) |
of this Section or subsection (c) of Section 11-5.3 does |
not result in the Department finding the applicant or |
recipient ineligible for assistance under Article V of this |
Code, the Department shall finalize the determination or |
|
redetermination of eligibility. |
(2) If the information discovered results in the |
Department finding the applicant or recipient ineligible |
for assistance, the Department shall provide notice as set |
forth in Section 11-7 of this Article. |
(3) If the information discovered is insufficient to |
determine that the applicant or recipient is eligible or |
ineligible, the Department shall provide written notice to |
the applicant or recipient which shall describe in |
sufficient detail the circumstances of the discrepancy, |
the information or documentation required, the manner in |
which the applicant or recipient may respond, and the |
consequences of failing to take action. The applicant or |
recipient shall have 10 business days to respond. |
(4) If the applicant or recipient does not respond to |
the notice, the Department shall deny assistance for |
failure to cooperate, in which case the Department shall |
provide notice as set forth in Section 11-7. Eligibility |
for assistance shall not be established until the |
discrepancy has been resolved. |
(5) If an applicant or recipient responds to the |
notice, the Department shall determine the effect of the |
information or documentation provided on the applicant's |
or recipient's case and shall take appropriate action. |
Written notice of the Department's action shall be provided |
as set forth in Section 11-7 of this Article. |
|
(6) Suspected cases of fraud shall be referred to the |
Department's Inspector General. |
(e) The Department shall adopt any rules necessary to |
implement this Section. |
(305 ILCS 5/11-5.3 new) |
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. 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.
|
(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 for |
the service
rendered to the Illinois Department or a |
governmental unit within 180 days after 12 months
of the date |
the service was rendered, then (a) upon the date the Illinois
|
Department or a governmental unit mails to the vendor |
information that it
is paying a bill in part or is refusing to |
pay a bill in whole or in part,
or (b) upon the date one year |
following the date the vendor submitted such
bill if the |
Illinois Department or a governmental unit fails to mail to
the |
vendor such payment information within one year following the |
date the
vendor submitted the bill; or
|
(2) If the vendor cannot prove that he submitted a bill for |
|
the service
rendered within 180 days after 12 months of the |
date the service was rendered, then upon
the date 12 months |
following the date the vendor rendered the
service to the |
recipient.
|
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. 86-430.)
|
(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 primary care provider, primary |
care pharmacy, primary dentist, primary podiatrist, or primary |
durable medical equipment provider . 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, as |
the Department
shall determine by rule; or
|
(2) when the designated primary provider type notifies |
the Department that it wishes to
withdraw from any |
obligation as primary provider type; or
|
(3) in other situations, as the Department shall |
provide by rule.
|
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 |
|
right to
designate a primary provider type of the |
recipient's own choosing willing to accept such |
designation
and that the recipient's failure to do so |
within a reasonable time may result
in such designation |
being made by the Department or (ii) the Department has
|
designated a primary provider type to assume |
responsibility for the recipient's care; and
|
(2) inform the recipient that the recipient has a right |
to appeal the
Department's determination to restrict the |
recipient's access to medical care
and provide the |
recipient with an explanation of how such appeal is to be
|
made. The notification shall also inform the recipient of |
the circumstances
under which unrestricted medical |
eligibility shall continue until a decision is
made on |
appeal and that if the recipient chooses to appeal, the |
recipient will
be able to review the medical payment data |
that was utilized by the Department
to decide that the |
recipient's access to medical care should be restricted.
|
(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 |
cards or misused or
falsely represented medical coverage;
|
(2) recipients found in possession of blank or forged |
prescription pads;
|
(3) recipients who knowingly assist providers in |
rendering excessive
services or defrauding the medical |
assistance program.
|
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
VIII-A of this Code.
|
(Source: P.A. 96-1501, eff. 1-25-11.)
|
(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 Department's |
policy or
rules and regulations, or with the terms and |
conditions prescribed by
the Illinois Department in its |
vendor agreement, which document shall be
developed by the |
Department as a result of negotiations with each vendor
|
category, including physicians, hospitals, long term care |
facilities,
pharmacists, optometrists, podiatrists and |
dentists setting forth the
terms and conditions applicable |
to the participation of each vendor
group in the program; |
or
|
(b) Such vendor has failed to keep or make available |
for inspection,
audit or copying, after receiving a written |
request from the Illinois
Department, such records |
regarding payments claimed for providing
services. This |
section does not require vendors to make available
patient |
records of patients for whom services are not reimbursed |
under
this Code; or
|
(c) Such vendor has failed to furnish any information |
requested by
the Department regarding payments for |
providing goods or services; or
|
(d) Such vendor has knowingly made, or caused to be |
made, any false
statement or representation of a material |
|
fact in connection with the
administration of the medical |
assistance program; or
|
(e) Such vendor has furnished goods or services to a |
recipient which
are (1) in excess of need his or her needs , |
(2) harmful to the recipient , or
(3) of grossly inferior |
quality, all of such determinations to be based
upon |
competent medical judgment and evaluations; or
|
(f) 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 which is a |
vendor;
or a partner in a partnership which is a vendor, |
either:
|
(1) was previously terminated , suspended, or |
excluded from participation in the Illinois
medical |
assistance program, or was terminated , suspended, or |
excluded from participation in another state or |
federal medical assistance or health care program a |
medical
assistance program in
another state that is of |
the same kind as the program of medical assistance
|
provided under Article V of this Code ; or
|
(2) was a person with management responsibility |
for a vendor
previously terminated , suspended, or |
excluded from participation in the Illinois medical |
assistance
program, or terminated , suspended, or |
|
excluded from participation in another state or |
federal a medical assistance or health care program in
|
another state that is of the same kind as the program |
of medical assistance
provided under Article V of this |
Code,
during the time of conduct which was the basis |
for
that vendor's termination , suspension, or |
exclusion ; or
|
(3) was 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 or |
limited liability company vendor
previously |
terminated , suspended, or excluded from participation |
in the Illinois medical assistance
program, or |
terminated , suspended, or excluded from participation |
in a state or federal medical assistance or health care |
program in
another state that is of the same kind as |
the program of medical assistance
provided under |
Article V of this Code,
during the time of conduct |
which
was the basis for that vendor's termination , |
suspension, or exclusion ; or
|
(4) was an owner of a sole proprietorship or |
partner of a
partnership previously terminated , |
suspended, or excluded
from participation in the |
Illinois medical assistance program, or terminated , |
suspended, or excluded from participation in a state or |
federal medical assistance or health care program in |
|
another state that is of
the same kind as the program |
of medical assistance provided under Article V of
this |
Code,
during the time of conduct
which was the basis |
for that vendor's termination , suspension, or |
exclusion ; or
|
(f-1) Such vendor has a delinquent debt owed to the |
Illinois Department; or
|
(g) 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 or
|
limited liability company vendor; an owner of a sole |
proprietorship which is a vendor;
or a partner in a |
partnership which is a vendor, either:
|
(1) has engaged in practices prohibited by |
applicable federal or
State law or regulation relating |
to the medical assistance program ; or
|
(2) was a person with management responsibility |
for a vendor at the
time that such vendor engaged in |
practices prohibited by applicable
federal or State |
law or regulation relating to the medical assistance
|
program ; or
|
(3) was an officer, or person owning, either |
directly or indirectly,
5% or more of the shares of |
stock or other evidences of ownership in a
vendor at |
the time such vendor engaged in practices prohibited by
|
|
applicable federal or State law or regulation relating |
to the medical
assistance program ; or
|
(4) was an owner of a sole proprietorship or |
partner of a
partnership which was a vendor at the time |
such vendor engaged in
practices prohibited by |
applicable federal or State law or regulation
relating |
to the medical assistance program ; or
|
(h) The direct or indirect ownership of the vendor |
(including the
ownership of a vendor that is a sole |
proprietorship, a partner's interest in a
vendor that is a |
partnership, or ownership of 5% or more of the shares of |
stock
or other
evidences of ownership in a corporate |
vendor) has been transferred by an
individual who is |
terminated , suspended, or excluded or barred from |
participating as a vendor to the
individual's spouse, |
child, brother, sister, parent, grandparent, grandchild,
|
uncle, aunt, niece, nephew, cousin, or relative by |
marriage.
|
(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 a felony offense based on fraud or willful
|
misrepresentation related to any of
the following:
|
(1) The medical assistance program under Article V of |
this Code.
|
(2) A medical assistance or health care program in |
another state that is of the same kind
as the program of |
medical assistance provided under Article V of this Code .
|
(3) The Medicare program under Title XVIII of the |
Social Security Act.
|
(4) The provision of health care services.
|
(5) A violation of this Code, as provided in Article |
VIIIA, or another state or federal medical assistance |
program or health care program. |
(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 a felony |
offense related to any of the following:
|
(1) Murder.
|
(2) A Class X felony under the Criminal Code of 1961.
|
(3) Sexual misconduct that may subject recipients to an |
undue risk of harm. |
(4) A criminal offense that may subject recipients to |
an undue risk of harm. |
(5) A crime of fraud or dishonesty. |
(6) A crime involving a controlled substance. |
(7) A misdemeanor relating to fraud, theft, |
embezzlement, breach of fiduciary responsibility, or other |
financial misconduct related to a health care program. |
(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 |
responsibility for the applicant; an officer or member of |
|
the board of directors of an applicant; an entity owning |
(directly or indirectly) 5% or more of the shares of stock |
or other evidences of ownership in a corporate vendor |
applicant; an owner of a sole proprietorship applicant; a |
partner in a partnership applicant; or a technical or other |
advisor to an applicant has a debt owed to the Illinois |
Department, and no payment arrangements acceptable to the |
Illinois Department have been made by the applicant. |
(2) The applicant or any person with management |
responsibility for the applicant; an officer or member of |
the board of directors of an applicant; an entity owning |
(directly or indirectly) 5% or more of the shares of stock |
or other evidences of ownership in a corporate vendor |
applicant; an owner of a sole proprietorship applicant; a |
partner in a partnership vendor applicant; or a technical |
or other advisor to an applicant was (i) a person with |
management responsibility, (ii) an officer or member of the |
board of directors of an applicant, (iii) an entity owning |
(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, (v) a partner in a |
partnership vendor, (vi) a technical or other advisor to a |
vendor, during a period of time where the conduct of that |
vendor resulted in a debt owed to the Illinois Department, |
and no payment arrangements acceptable to the Illinois |
Department have been made by that vendor. |
|
(3) There is a credible allegation of the use, |
transfer, or lease of assets of any kind to an applicant |
from a current or prior vendor who has a debt owed to the |
Illinois Department, no payment arrangements acceptable to |
the Illinois Department have been made by that vendor or |
the vendor's alternate payee, and the applicant knows or |
should have known of such debt. |
(4) There is a credible allegation of a transfer of |
management responsibilities, or direct or indirect |
ownership, to an applicant from a current or prior vendor |
who has a debt owed to the Illinois Department, and no |
payment arrangements acceptable to the Illinois Department |
have been made by that vendor or the vendor's alternate |
payee, and the applicant knows or should have known of such |
debt. |
(5) There is a credible allegation of the use, |
transfer, or lease of assets of any kind to an applicant |
who is a spouse, child, brother, sister, parent, |
grandparent, grandchild, uncle, aunt, niece, relative by |
marriage, nephew, cousin, or relative of a current or prior |
vendor who has a debt owed to the Illinois Department and |
no payment arrangements acceptable to the Illinois |
Department have been made. |
(6) There is a credible allegation that the applicant's |
previous affiliations with a provider of medical services |
that has an uncollected debt, a provider that has been or |
|
is subject to a payment suspension under a federal health |
care program, or a provider that has been previously |
excluded from participation in the medical assistance |
program, poses a risk of fraud, waste, or abuse to the |
Illinois Department. |
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 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 |
licensed , certified, or authorized ;
|
(2) within 30 days of the date when such vendor's |
professional
license, certification or other authorization |
has been refused renewal , restricted,
or has been revoked, |
suspended , or otherwise terminated; or
|
(3) if such vendor has been convicted of a violation of |
|
this Code, as
provided in Article VIIIA.
|
(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 corporate 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 in another state that |
is of the
kind provided under Article V, (iii) the Medicare |
program under Title XVIII of
the Social Security Act , or (iii) |
(iv) 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 in another |
state
that is of the kind provided under Article V, (iii) the |
Medicare program under
Title XVIII of the Social Security Act , |
or (iii) (iv) 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 |
from a vendor or alternate payee: (i) for services rendered |
in violation of the Illinois Department's provider |
|
notices, statutes, rules, and regulations; (ii) for |
services rendered in violation of the terms and conditions |
prescribed by the Illinois Department in its vendor |
agreement; (iii) for any vendor who fails to grant the |
Office of Inspector General timely access to full and |
complete records, including, but not limited to, records |
relating to 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; |
this subsection (E) does not require vendors to make |
available the medical records of patients for whom services |
are not reimbursed under this Code or to provide access to |
medical records more than 6 years old; (iv) when the vendor |
has knowingly made, or caused to be made, any false |
statement or representation of a material fact in |
connection with the administration of the medical |
assistance program; or (v) when the vendor previously |
rendered services while terminated, suspended, or excluded |
from participation in the medical assistance program or |
while terminated or excluded from participation in another |
state or federal medical assistance or health care program. |
(2) Notwithstanding any other provision of law, if a |
vendor has the same taxpayer identification number |
|
(assigned under Section 6109 of the Internal Revenue Code |
of 1986) as is assigned to a vendor with past-due financial |
obligations to the Illinois Department, the Illinois |
Department may make any necessary adjustments to payments |
to that vendor in order to satisfy any past-due |
obligations, regardless of whether the vendor is assigned a |
different billing number under the medical assistance |
program.
|
If the Illinois Department establishes through an |
administrative
hearing that the overpayments resulted from the |
vendor
or alternate payee knowingly willfully making, using, or |
causing to be made or used , a false record or statement to |
obtain payment or other benefit from or
misrepresentation of a |
material fact in connection with billings and payments
under |
the medical assistance program under Article V, the Department |
may
recover interest on the amount of the payment or other |
benefit overpayments at the rate of 5% per annum.
In addition |
to any other penalties that may be prescribed by law, such a |
vendor or alternate payee shall be subject to civil penalties |
consisting of an amount not to exceed 3 times the amount of |
payment or other benefit resulting from each such false record |
or statement, and the sum of $2,000 for each such false record |
or statement for payment or other benefit. For purposes of this |
paragraph,
"knowingly" "willfully" means that a vendor or |
alternate payee with respect to information: (i) has person |
makes a statement or representation with
actual knowledge of |
|
the information, (ii) acts in deliberate ignorance of the truth |
or falsity of the information, or (iii) acts in reckless |
disregard of the truth or falsity of the information. No proof |
of specific intent to defraud is required. that it was false, |
or makes a statement or representation with
knowledge of facts |
or information that would cause one to be aware that
the |
statement or representation was false when made.
|
(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 during the pendency |
of any
proceeding 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 a |
felony 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 provided in another state which is of the kind |
provided under
Article V of this Code, (iii) the Medicare |
program under Title XVIII of the
Social Security Act , or (iii) |
(iv) the provision of health care services:
|
(1) If the vendor or alternate payee is a corporation: |
an officer of the corporation
or an individual who owns, |
either directly or indirectly, 5% or more
of the shares of |
|
stock or other evidence of ownership of the
corporation.
|
(2) If the vendor is a sole proprietorship: the owner |
of the sole
proprietorship.
|
(3) If the vendor or alternate payee is a partnership: |
a partner in the partnership.
|
(4) If the vendor or alternate payee is any other |
business entity authorized by law
to transact business in |
this State: an officer of the entity or an
individual who |
owns, either directly or indirectly, 5% or more of the
|
evidences of ownership of the entity.
|
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 costs |
imposed, or part of any fine, recovery amount, other |
sanction, or cost imposed, remaining unpaid after the |
exhaustion of or the failure to exhaust judicial review |
procedures under the Illinois Administrative Review Law is |
a debt due and owing the State and may be collected using |
all remedies available under the law. |
(2) After expiration of the period in which judicial |
review under the Illinois Administrative Review Law may be |
sought for a final administrative decision, unless stayed |
by a court of competent jurisdiction, the findings, |
decision, and order of the Director may be enforced in the |
same manner as a judgment entered by a court of competent |
jurisdiction. |
(3) In any case in which any person or entity has |
failed to comply with a judgment ordering or imposing any |
fine or other sanction, any expenses incurred by the |
Illinois Department to enforce the judgment, including, |
but not limited to, attorney's fees, court costs, and costs |
related to property demolition or foreclosure, after they |
|
are fixed by a court of competent jurisdiction or the |
Director, shall be a debt due and owing the State and may |
be collected in accordance with applicable law. Prior to |
any expenses being fixed by a final administrative decision |
pursuant to this subsection (F-15), the Illinois |
Department shall provide notice to the individual or entity |
that states that the individual or entity shall appear at a |
hearing before the administrative hearing officer to |
determine whether the individual or entity has failed to |
comply with the judgment. The notice shall set the date for |
such a hearing, which shall not be less than 7 days from |
the date that notice is served. If notice is served by |
mail, the 7-day period shall begin to run on the date that |
the notice was deposited in the mail. |
(4) Upon being recorded in the manner required by |
Article XII of the Code of Civil Procedure or by the |
Uniform Commercial Code, a lien shall be imposed on the |
real estate or personal estate, or both, of the individual |
or entity in the amount of any debt due and owing the State |
under this Section. The lien may be enforced in the same |
manner as a judgment of a court of competent jurisdiction. |
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. |
(5) The Director may set aside any judgment entered by
|
|
default and set a new hearing date upon a petition filed at
|
any time (i) if the petitioner's failure to appear at the
|
hearing was for good cause, or (ii) if the petitioner
|
established that the Department did not provide proper
|
service of process. If any judgment is set aside pursuant
|
to this paragraph (5), the hearing officer shall have
|
authority to enter an order extinguishing any lien which
|
has been recorded for any debt due and owing the Illinois
|
Department as a result of the vacated default judgment. |
(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 Non-emergency transportation .
|
(1) Notwithstanding any other provision in this |
Section, for non-emergency
transportation vendors, the |
Department may terminate , suspend, or exclude vendors who |
pose a risk of fraud, waste, abuse, or harm the vendor from
|
participation in the medical assistance program prior
to an |
evidentiary hearing but after reasonable notice and |
opportunity to
respond as established by the Department by |
rule.
|
|
(2) Vendors who pose a risk of fraud, waste, abuse, or |
harm of non-emergency medical transportation services, as |
defined
by the Department by rule, shall submit to a |
fingerprint-based criminal
background check on current and |
future information available in the State
system and |
current information available through the Federal Bureau |
of
Investigation's system by submitting all necessary fees |
and information in the
form and manner
prescribed by the |
Department of State Police. The following individuals |
shall
be subject to the check:
|
(A) In the case of a vendor that is a corporation, |
every shareholder
who owns, directly or indirectly, 5% |
or more of the outstanding shares of
the corporation.
|
(B) In the case of a vendor that is a partnership, |
every partner.
|
(C) In the case of a vendor that is a sole |
proprietorship, the sole
proprietor.
|
(D) Each officer or manager of the vendor.
|
Each such vendor shall be responsible for payment of |
the cost of the
criminal background check.
|
(3) Vendors who pose a risk of fraud, waste, abuse, or |
harm of non-emergency medical transportation services may |
be
required to post a surety bond. The Department shall |
establish, by rule, the
criteria and requirements for |
determining when a surety bond must be posted and
the value |
of the bond.
|
|
(4) The Department, or its agents, may refuse to accept |
requests for authorization from specific vendors who pose a |
risk of fraud, waste, abuse, or harm
non-emergency |
transportation authorizations , including prior-approval |
and
post-approval requests, for a specific non-emergency |
transportation vendor if:
|
(A) the Department has initiated a notice of |
termination , suspension, or exclusion of the
vendor |
from participation in the medical assistance program; |
or
|
(B) the Department has issued notification of its |
withholding of
payments pursuant to subsection (F-5) |
of this Section; or
|
(C) the Department has issued a notification of its |
withholding of
payments due to reliable evidence of |
fraud or willful misrepresentation
pending |
investigation.
|
(5) As used in this subsection, the following terms are |
defined as follows: |
(A) "Fraud" means an intentional deception or |
misrepresentation made by a person with the knowledge |
that the deception could result in some unauthorized |
benefit to himself or herself or some other person. It |
includes any act that constitutes fraud under |
applicable federal or State law. |
(B) "Abuse" means provider practices that are |
|
inconsistent with sound fiscal, business, or medical |
practices and that result in an unnecessary cost to the |
medical assistance program or in reimbursement for |
services that are not medically necessary or that fail |
to meet professionally recognized standards for health |
care. It also includes recipient practices that result |
in unnecessary cost to the medical assistance program. |
Abuse does not include diagnostic or therapeutic |
measures conducted primarily as a safeguard against |
possible vendor liability. |
(C) "Waste" means the unintentional misuse of |
medical assistance resources, resulting in unnecessary |
cost to the medical assistance program. Waste does not |
include diagnostic or therapeutic measures conducted |
primarily as a safeguard against possible vendor |
liability. |
(D) "Harm" means physical, mental, or monetary |
damage to recipients or to the medical assistance |
program. |
(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 or |
transfer of
residents, or both.
|
(6) State monitoring.
|
(7) Denial of all payments when the U.S. Department of |
Health and Human Services Health Care Finance |
Administration has
imposed this sanction.
|
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 |
required to register as an alternate payee in the Medical |
Assistance Program with the Illinois Department. |
(b) If a practitioner designates an alternate payee, |
the alternate payee and practitioner shall be jointly and |
severally liable to the Department for payments made to the |
alternate payee. Pursuant to subsection (E) of this |
Section, any Department action to suspend or deny payment |
or recover money or overpayments from an alternate payee |
shall be subject to an administrative hearing. |
(c) Registration as an alternate payee or alternate |
payees in the Illinois Medical Assistance Program shall be |
conditional. At any time, the Illinois Department may deny |
or cancel any alternate payee's registration in the |
|
Illinois Medical Assistance Program without cause. Any |
such denial or cancellation is not subject to an |
administrative hearing. |
(d) The Illinois Department may seek a revocation of |
any alternate payee, and all owners, officers, and |
individuals with management responsibility for such |
alternate payee shall be permanently prohibited from |
participating as an owner, an officer, or an individual |
with management responsibility with an alternate payee in |
the Illinois Medical Assistance Program, if after |
reasonable notice and opportunity for a hearing the |
Illinois Department finds that: |
(1) the alternate payee is not complying with the |
Department's policy or rules and regulations, or with |
the terms and conditions prescribed by the Illinois |
Department in its alternate payee registration |
agreement; or |
(2) the alternate payee has failed to keep or make |
available for inspection, audit, or copying, after |
receiving a written request from the Illinois |
Department, such records regarding payments claimed as |
an alternate payee; or |
(3) the alternate payee has failed to furnish any |
information requested by the Illinois Department |
regarding payments claimed as an alternate payee; or |
(4) the alternate payee has knowingly made, or |
|
caused to be made, any false statement or |
representation of a material fact in connection with |
the administration of the Illinois Medical Assistance |
Program; or |
(5) the alternate payee, a person with management |
responsibility for an alternate payee, 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 alternate payee, or a partner |
in a partnership which is an alternate payee: |
(a) was previously terminated , suspended, or |
excluded from participation as a vendor in the |
Illinois Medical Assistance Program, or was |
previously revoked as an alternate payee in the |
Illinois Medical Assistance Program, or was |
terminated , suspended, or excluded from |
participation as a vendor in a medical assistance |
program in another state that is of the same kind |
as the program of medical assistance provided |
under Article V of this Code; or |
(b) was a person with management |
responsibility for a vendor previously terminated , |
suspended, or excluded from participation as a |
vendor in the Illinois Medical Assistance Program, |
or was previously revoked as an alternate payee in |
the Illinois Medical Assistance Program, or was |
|
terminated , suspended, or excluded from |
participation as a vendor in a medical assistance |
program in another state that is of the same kind |
as the program of medical assistance provided |
under Article V of this Code, during the time of |
conduct which was the basis for that vendor's |
termination , suspension, or exclusion or alternate |
payee's revocation; or |
(c) was 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 previously terminated , suspended, |
or excluded from participation as a vendor in the |
Illinois Medical Assistance Program, or was |
previously revoked as an alternate payee in the |
Illinois Medical Assistance Program, or was |
terminated , suspended, or excluded from |
participation as a vendor in a medical assistance |
program in another state that is of the same kind |
as the program of medical assistance provided |
under Article V of this Code, during the time of |
conduct which was the basis for that vendor's |
termination , suspension, or exclusion ; or |
(d) was an owner of a sole proprietorship or |
partner in a partnership previously terminated , |
suspended, or excluded from participation as a |
|
vendor in the Illinois Medical Assistance Program, |
or was previously revoked as an alternate payee in |
the Illinois Medical Assistance Program, or was |
terminated , suspended, or excluded from |
participation as a vendor in a medical assistance |
program in another state that is of the same kind |
as the program of medical assistance provided |
under Article V of this Code, during the time of |
conduct which was the basis for that vendor's |
termination , suspension, or exclusion or alternate |
payee's revocation; or |
(6) the alternate payee, a person with management |
responsibility for an alternate payee, 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 alternate payee, or a partner |
in a partnership which is an alternate payee: |
(a) has engaged in conduct prohibited by |
applicable federal or State law or regulation |
relating to the Illinois Medical Assistance |
Program; or |
(b) was a person with management |
responsibility for a vendor or alternate payee at |
the time that the vendor or alternate payee engaged |
in practices prohibited by applicable federal or |
State law or regulation relating to the Illinois |
|
Medical Assistance Program; or |
(c) was an officer, or person owning, either |
directly or indirectly, 5% or more of the shares of |
stock or other evidences of ownership in a vendor |
or alternate payee at the time such vendor or |
alternate payee engaged in practices prohibited by |
applicable federal or State law or regulation |
relating to the Illinois Medical Assistance |
Program; or |
(d) was an owner of a sole proprietorship or |
partner in a partnership which was a vendor or |
alternate payee at the time such vendor or |
alternate payee engaged in practices prohibited by |
applicable federal or State law or regulation |
relating to the Illinois Medical Assistance |
Program; or |
(7) the direct or indirect ownership of the vendor |
or alternate payee (including the ownership of a vendor |
or alternate payee that is a partner's interest in a |
vendor or alternate payee, or ownership of 5% or more |
of the shares of stock or other evidences of ownership |
in a corporate vendor or alternate payee) has been |
transferred by an individual who is terminated , |
suspended, or excluded or barred from participating as |
a vendor or is prohibited or revoked as an alternate |
payee to the individual's spouse, child, brother, |
|
sister, parent, grandparent, grandchild, uncle, aunt, |
niece, nephew, cousin, or relative by marriage. |
(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 upon |
receipt of evidence, received from State or federal law |
enforcement or federal oversight agencies or from the results |
of a preliminary Department audit and determined by the |
Department to be credible , 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
|
withholding of program payments within 5 days of taking |
such action. The notice must set forth the general |
allegations as to the nature of the withholding action, but |
|
need not disclose any specific information concerning its |
ongoing investigation. The notice must do all of the |
following: |
(1) State that payments are being withheld in
|
accordance with this subsection. |
(2) State that the withholding is for a temporary
|
period, as stated in paragraph (b) of this
subsection, |
and cite the circumstances under which
withholding |
will be terminated. |
(3) Specify, when appropriate, which type or types
|
of Medicaid claims withholding is effective. |
(4) Inform the provider or alternate payee of the
|
right to submit written evidence for reconsideration |
of the withholding by
the Illinois Department. |
(5) Inform the provider or alternate payee that a |
written request may be made to the Illinois Department |
for full or partial release of withheld payments and |
that such requests may be made at any time after the |
Department first withholds such payments.
|
(b) All withholding-of-payment actions under this
|
subsection shall be temporary and shall not continue after |
any of the following: |
(1) The Illinois Department or the prosecuting
|
authorities determine that there is insufficient
|
evidence of fraud or willful misrepresentation by the
|
provider or alternate payee. |
|
(2) Legal proceedings related to the provider's or
|
alternate payee's alleged fraud, willful
|
misrepresentation, violations of this Act, or
|
violations of the Illinois Department's administrative
|
rules are completed. |
(3) The withholding of payments for a period of 3 |
years.
|
(c) The Illinois Department may adopt all rules |
necessary
to implement this subsection (K).
|
(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 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 |
withholding of program payments within 5 days of taking |
such action. The notice must set forth the general |
allegations as to the nature of the withholding action but |
need not disclose any specific information concerning its |
ongoing investigation. The notice must do all of the |
following: |
(1) State that payments are being withheld in |
accordance with this subsection. |
(2) State that the withholding is for a temporary |
period, as stated in paragraph (b) of this subsection, |
and cite the circumstances under which withholding |
will be terminated. |
(3) Specify, when appropriate, which type or types |
of claims are withheld. |
(4) Inform the provider or alternate payee of the |
right to request a hearing or a reconsideration of the |
withholding by the Illinois Department, including the |
ability to submit written evidence. |
|
(5) Inform the provider or alternate payee that a |
written request may be made to the Illinois Department |
for a hearing or a reconsideration for the full or |
partial release of withheld payments and that such |
requests may be made at any time after the Illinois |
Department first withholds such payments. |
(b) All withholding of payment actions under this |
subsection shall be temporary and shall not continue after |
any of the following: |
(1) The Illinois Department determines that there |
is insufficient evidence of fraud, or the provider or |
alternate payee demonstrates clear cooperation with |
the Illinois Department, as determined by the Illinois |
Department, such that the circumstances do not give |
rise to the need for withholding of payments; or |
(2) The withholding of payments has lasted for a |
period in excess of 3 years. |
(c) The Illinois Department may adopt all rules |
necessary to implement this subsection (K-5). |
(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 and the ID/DD |
Community Care Act from the provisions of subsections (A-15), |
(B), and (C) of this Section if the licensed entity is in |
receivership. |
(Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
|
(305 ILCS 5/12-4.38)
|
Sec. 12-4.38. Special FamilyCare provisions. (a) 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. |
(b) Each person enrolled in the FamilyCare Program as of |
the effective date of this amendatory Act of the 96th General |
Assembly whose income exceeds 185% of the Federal Poverty |
Level, but is not more than 400% of the Federal Poverty Level, |
may remain enrolled in the FamilyCare Program pursuant to this |
subsection so long as that person continues to meet the |
eligibility criteria established under the emergency rule at 89 |
Ill. Adm. Code 120 (Illinois Register Volume 31, page 15854) |
filed November 7, 2007. In no case may a person continue to be |
enrolled in the FamilyCare Program pursuant to this subsection |
if the person's income rises above 400% of the Federal Poverty |
Level or falls below 185% of the Federal Poverty Level at any |
subsequent time. Nothing contained in this subsection shall |
prevent an individual from enrolling in the FamilyCare Program |
as authorized by paragraph 15 of Section 5-2 of this Code if he |
or she otherwise qualifies under that Section. |
(c) In implementing the provisions of this amendatory Act |
of the 96th General Assembly, the Department of Healthcare and |
Family Services is authorized to adopt only those rules |
necessary, including emergency rules. Nothing in this |
amendatory Act of the 96th General Assembly 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.
|
(Source: P.A. 96-20, eff. 6-30-09.) |
(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 |
Subject to funding availability, the Department of Healthcare |
and Family Services may shall 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.)
|
(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 is 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, or |
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.)
|
(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' integrity
functions, which include, but are not |
limited to, the following:
|
(1) Investigation of misconduct by employees, vendors, |
contractors and
medical providers, except for allegations |
of violations of the State Officials and Employees Ethics |
Act which shall be referred to the Office of the Governor's |
Executive Inspector General for investigation.
|
(2) Prepayment and post-payment audits Audits of |
medical providers related to ensuring that appropriate
|
payments are made for services rendered and to the |
prevention and recovery of overpayments.
|
(3) Monitoring of quality assurance programs |
administered by the Department of Healthcare and Family
|
Services generally related to the
medical assistance |
program and specifically related to any managed care
|
program .
|
(4) Quality control measurements of the programs |
|
administered by the
Department of Healthcare and Family |
Services.
|
(5) Investigations of fraud or intentional program |
violations committed by
clients of the Department of |
Healthcare and Family Services.
|
(6) Actions initiated against contractors , vendors, or |
medical providers for any of
the following reasons:
|
(A) Violations of the medical assistance program.
|
(B) Sanctions against providers brought in |
conjunction with the
Department of Public Health or the |
Department of Human Services (as successor
to the |
Department of Mental Health and Developmental |
Disabilities).
|
(C) Recoveries of assessments against hospitals |
and long-term care
facilities.
|
(D) Sanctions mandated by the United States |
Department of Health and
Human Services against |
medical providers.
|
(E) Violations of contracts related to any |
programs administered by the Department of Healthcare
|
and Family Services managed care programs .
|
(7) Representation of the Department of Healthcare and |
Family Services at
hearings with the Illinois Department of |
Financial and Professional Regulation in actions
taken |
against professional licenses held by persons who are in |
violation of
orders for child support payments.
|
|
(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 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 Medical Assistance Program . 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 |
federal law enforcement
agencies.
|
(3) The various Inspectors General of federal agencies |
overseeing the
programs administered by the
Department of |
Healthcare and Family Services.
|
(4) The various Inspectors General of any other State |
agencies with
responsibilities for portions of programs |
primarily administered by the
Department of Healthcare and |
Family Services.
|
(5) The Offices of the several United States Attorneys |
in Illinois.
|
(6) The several State's Attorneys.
|
(7) The offices of the Centers for Medicare and |
Medicaid Services that administer the Medicare and |
Medicaid integrity programs. |
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 public aid |
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 |
information, including the
number of providers at various |
Medicaid earning levels.
|
(2) The number of audits of the medical assistance
|
program and the dollar savings resulting from those audits.
|
(3) The number of prescriptions rejected annually |
under the
Department of Healthcare and Family Services' |
Refill Too Soon program and the
dollar savings resulting |
from that program.
|
(4) Provider sanctions, in the aggregate, including |
terminations and
suspensions.
|
(5) A detailed summary of the investigations |
undertaken in the previous
fiscal year. These summaries |
shall comply with all laws and rules regarding
maintaining |
confidentiality in the public aid programs.
|
(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 public aid
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. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09; |
96-1316, eff. 1-1-11.)
|
(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, 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 |
1886(d)(4) of the
Social Security Act shall not be used in |
the reimbursement system
established under this Section. |
Rather, the Illinois Department shall
establish by rule |
|
Medicaid weighting factors to be used in the reimbursement
|
system established under this Section.
|
(2) The Illinois Department shall define by rule those |
hospitals or
distinct parts of hospitals that shall be |
exempt from the reimbursement
system established under |
this Section. In defining such hospitals, the
Illinois |
Department shall take into consideration those hospitals |
exempt
from the Medicare Prospective Payment System as of |
September 1, 1991. For
hospitals defined as exempt under |
this subsection, the Illinois Department
shall by rule |
establish a reimbursement system for payment of inpatient
|
hospital services rendered on and after September 1, 1991. |
For all
hospitals that are children's hospitals as defined |
in Section 5-5.02 of
this Code, the reimbursement |
methodology shall, through June 30, 1992, net
of all |
applicable fees, at least equal each children's hospital |
1990 ICARE
payment rates, indexed to the current year by |
application of the DRI hospital
cost index from 1989 to the |
year in which payments are made. 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
Department of Mental Health and |
Developmental Disabilities (or its successor,
the |
Department of Human Services) for hospital inpatient |
services rendered on
or after July 1, 1995, the Illinois |
Department shall reimburse children's
hospitals, as |
|
defined in 89 Illinois Administrative Code Section |
149.50(c)(3),
at the rates in effect on June 30, 1995, and |
shall reimburse all other
hospitals at the rates in effect |
on June 30, 1995, less the portion of such
rates attributed |
by the Illinois Department to the cost of medical |
education.
For inpatient hospital services provided on or |
after August 1, 1998, the
Illinois Department may establish |
by rule a means of adjusting the rates of
children's |
hospitals, as defined in 89 Illinois Administrative Code |
Section
149.50(c)(3), that did not meet that definition on |
June 30, 1995, in order
for the inpatient hospital rates of |
such hospitals to take into account the
average inpatient |
hospital rates of those children's hospitals that did meet
|
the definition of children's hospitals on June 30, 1995.
|
(3) (Blank)
|
(4) Notwithstanding any other provision of this |
Section, hospitals
that on August 31, 1991, have a contract |
with the Illinois Department under
Section 3-4 of the |
Illinois Health Finance Reform Act may elect to continue
to |
be reimbursed at rates stated in such contracts for general |
and specialty
care.
|
(5) In addition to any payments made under this |
subsection (a), the
Illinois Department shall make the |
adjustment payments required by Section
5-5.02 of this |
Code; provided, that in the case of any hospital reimbursed
|
under a per case methodology, the Illinois Department shall |
|
add an amount
equal to the product of the hospital's |
average length of stay, less one
day, multiplied by 20, for |
inpatient hospital services rendered on or
after September |
1, 1991 and on or before September 30, 1992.
|
(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, |
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 |
Code,
the Illinois Department shall develop a |
reimbursement methodology that shall
reimburse Critical |
Care Access Hospitals for the specialized services that
|
qualify them as Critical Care Access Hospitals. No |
adjustment payments shall be
made under this subsection on |
or after July 1, 1995.
|
(2) "Critical Care Access Hospitals" includes, but is |
not limited to,
hospitals that meet at least one of the |
following criteria:
|
(A) Hospitals located outside of a metropolitan |
statistical area that
are designated as Level II |
Perinatal Centers and that provide a
disproportionate |
share of perinatal services to recipients; or
|
(B) Hospitals that are designated as Level I Trauma |
Centers (adult
or pediatric) and certain Level II |
Trauma Centers as determined by the
Illinois |
|
Department; or
|
(C) Hospitals located outside of a metropolitan |
statistical area and
that provide a disproportionate |
share of obstetrical services to recipients.
|
(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. 96-1382, eff. 1-1-11.)
|
(305 ILCS 5/14-11 new) |
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 |
the vendor of the APR-DRG system, adjusted to reflect |
characteristics of the Illinois Medical Assistance |
population. |
(2) An updated outlier payment methodology based on |
current data and consistent with the APR-DRG system. |
(3) The use of policy adjusters to enhance payments to |
hospitals treating a high percentage of individuals |
covered by the Medical Assistance program and uninsured |
patients. |
(4) Reimbursement for inpatient specialty services |
such as psychiatric, rehabilitation, and long-term acute |
care using updated per diem rates that account for service |
acuity. |
(5) The creation of one or more transition funding |
pools to preserve access to care and to ensure financial |
stability as hospitals transition to the new payment |
system. |
(6) Whether, beginning July 1, 2014, some of the static |
|
adjustment payments financed by General Revenue funds |
should be used as part of the base payment system, |
including as policy adjusters to recognize the additional |
costs of certain services, such as pediatric or neonatal, |
or providers, such as trauma centers, Critical Access |
Hospitals, or high Medicaid hospitals, or for services to |
uninsured patients. |
(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.
|
(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). "Base amount" means $108,800,000 multiplied |
by a
fraction, the numerator of which is the number of days |
represented by the
payments in question and the denominator of |
which is 365.
|
(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. 87-13; 88-85; 88-554, eff. 7-26-94.)
|
Section 85. The Pediatric Palliative Care Act is amended by |
adding Section 3 as follows: |
|
(305 ILCS 60/3 new) |
Sec. 3. Act inoperative. Notwithstanding any other |
provision of law, this Act is inoperative on and after July 1, |
2012. |
(305 ILCS 5/5-5.4a rep.) |
(305 ILCS 5/5-5.4c rep.) |
(305 ILCS 5/12-4.36 rep.) |
Section 88. The Illinois Public Aid Code is amended by |
repealing Sections 5-5.4a, 5-5.4c, and 12-4.36. |
Section 90. The Senior Citizens and Disabled Persons |
Property Tax Relief and
Pharmaceutical Assistance Act is |
amended by changing the title of the Act and Sections 1, 1.5, |
2, 3.05a, 3.10, 4, 4.05, 5, 6, 7, 8, 9, 12, and 13 as follows:
|
(320 ILCS 25/Act title)
|
An Act in relation to the payment of grants to enable the |
elderly and
the disabled to acquire or retain private housing |
and to acquire
prescription drugs .
|
(320 ILCS 25/1) (from Ch. 67 1/2, par. 401)
|
Sec. 1. Short title; common name. This Article shall be |
known and may be cited as the Senior Citizens and
Disabled |
Persons Property Tax Relief and Pharmaceutical Assistance
Act. |
|
Common references to the "Circuit Breaker Act" mean this |
Article. As used in this Article, "this Act" means this |
Article.
|
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/1.5) |
Sec. 1.5. Implementation of Executive Order No. 3 of 2004 ; |
termination of the Illinois Senior Citizens and Disabled |
Persons Pharmaceutical Assistance Program . Executive Order No. |
3 of 2004, in part, provided for the
transfer of the programs |
under this Act from the Department of
Revenue to the Department |
on Aging and the Department of
Healthcare and Family Services. |
It is the purpose of this
amendatory Act of the 96th General |
Assembly to conform this Act
and certain related provisions of |
other statutes to that
Executive Order. This amendatory Act of |
the 96th General
Assembly also makes other substantive changes
|
to this Act.
|
It is the purpose of this amendatory Act of the 97th |
General Assembly to terminate the Illinois Senior Citizens and |
Disabled Persons Pharmaceutical Assistance Program on July 1, |
2012. |
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/2) (from Ch. 67 1/2, par. 402)
|
Sec. 2. Purpose. The purpose of this Act is to provide |
incentives to the senior citizens
and disabled persons of this |
|
State to acquire and retain private housing of
their choice and |
at the same time to relieve those citizens from the
burdens of |
extraordinary property taxes and rising drug costs against |
their increasingly
restricted earning power, and thereby to |
reduce the requirements for public
housing in this State.
|
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/3.05a) |
Sec. 3.05a. Additional resident. "Additional resident"
|
means a person who (i) is living in the same residence with a
|
claimant for the claim year and at the time of filing the
|
claim, (ii) is not the spouse of the claimant, (iii) does not
|
file a separate claim under this Act for the same period, and
|
(iv) receives more than half of his or her total financial
|
support for that claim year from the household. Prior to July |
1, 2012, an An additional resident who meets qualifications may |
receive pharmaceutical assistance based on a claimant's |
application.
|
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/3.10) (from Ch. 67 1/2, par. 403.10)
|
Sec. 3.10. Regulations. "Regulations" includes both rules |
promulgated and forms prescribed by the applicable
Department. |
In this Act, references to the rules of the Department on Aging
|
or the Department of Healthcare and Family Services , in effect |
prior to July 1, 2012, shall be
deemed to include, in |
|
appropriate cases, the corresponding
rules adopted by the |
Department of Revenue, to the extent that
those rules continue |
in force under Executive Order No. 3 of
2004.
|
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
|
Sec. 4. Amount of Grant.
|
(a) In general. Any individual 65 years or older or any |
individual who will
become 65 years old during the calendar |
year in which a claim is filed, and any
surviving spouse of |
such a claimant, who at the time of death received or was
|
entitled to receive a grant pursuant to this Section, which |
surviving spouse
will become 65 years of age within the 24 |
months immediately following the
death of such claimant and |
which surviving spouse but for his or her age is
otherwise |
qualified to receive a grant pursuant to this Section, and any
|
disabled person whose annual household income is less than the |
income eligibility limitation, as defined in subsection (a-5)
|
and whose household is liable for payment of property taxes |
accrued or has
paid rent constituting property taxes accrued |
and is domiciled in this State
at the time he or she files his |
or her claim is entitled to claim a
grant under this Act.
With |
respect to claims filed by individuals who will become 65 years |
old
during the calendar year in which a claim is filed, the |
amount of any grant
to which that household is entitled shall |
be an amount equal to 1/12 of the
amount to which the claimant |
|
would otherwise be entitled as provided in
this Section, |
multiplied by the number of months in which the claimant was
65 |
in the calendar year in which the claim is filed.
|
(a-5) Income eligibility limitation. For purposes of this |
Section, "income eligibility limitation" means an amount for |
grant years 2008 and thereafter: |
(1) less than $22,218 for a household containing one |
person; |
(2) less than $29,480 for a household containing 2 |
persons; or |
(3) less than $36,740 for a
household containing 3 or |
more persons. |
For 2009 claim year applications submitted during calendar |
year 2010, a household must have annual household income of |
less than $27,610 for a household containing one person; less |
than $36,635 for a household containing 2 persons; or less than |
$45,657 for a household containing 3 or more persons. |
The Department on Aging may adopt rules such that on |
January 1, 2011, and thereafter, the foregoing household income |
eligibility limits may be changed to reflect the annual cost of |
living adjustment in Social Security and Supplemental Security |
Income benefits that are applicable to the year for which those |
benefits are being reported as income on an application. |
If a person files as a surviving spouse, then only his or |
her income shall be counted in determining his or her household |
income. |
|
(b) Limitation. Except as otherwise provided in |
subsections (a) and (f)
of this Section, the maximum amount of |
grant which a claimant is
entitled to claim is the amount by |
which the property taxes accrued which
were paid or payable |
during the last preceding tax year or rent
constituting |
property taxes accrued upon the claimant's residence for the
|
last preceding taxable year exceeds 3 1/2% of the claimant's |
household
income for that year but in no event is the grant to |
exceed (i) $700 less
4.5% of household income for that year for |
those with a household income of
$14,000 or less or (ii) $70 if |
household income for that year is more than
$14,000.
|
(c) Public aid recipients. If household income in one or |
more
months during a year includes cash assistance in excess of |
$55 per month
from the Department of Healthcare and Family |
Services or the Department of Human Services (acting
as |
successor to the Department of Public Aid under the Department |
of Human
Services Act) which was determined under regulations |
of
that Department on a measure of need that included an |
allowance for actual
rent or property taxes paid by the |
recipient of that assistance, the amount
of grant to which that |
household is entitled, except as otherwise provided in
|
subsection (a), shall be the product of (1) the maximum amount |
computed as
specified in subsection (b) of this Section and (2) |
the ratio of the number of
months in which household income did |
not include such cash assistance over $55
to the number twelve. |
If household income did not include such cash assistance
over |
|
$55 for any months during the year, the amount of the grant to |
which the
household is entitled shall be the maximum amount |
computed as specified in
subsection (b) of this Section. For |
purposes of this paragraph (c), "cash
assistance" does not |
include any amount received under the federal Supplemental
|
Security Income (SSI) program.
|
(d) Joint ownership. If title to the residence is held |
jointly by
the claimant with a person who is not a member of |
his or her household,
the amount of property taxes accrued used |
in computing the amount of grant
to which he or she is entitled |
shall be the same percentage of property
taxes accrued as is |
the percentage of ownership held by the claimant in the
|
residence.
|
(e) More than one residence. If a claimant has occupied |
more than
one residence in the taxable year, he or she may |
claim only one residence
for any part of a month. In the case |
of property taxes accrued, he or she
shall prorate 1/12 of the |
total property taxes accrued on
his or her residence to each |
month that he or she owned and occupied
that residence; and, in |
the case of rent constituting property taxes accrued,
shall |
prorate each month's rent payments to the residence
actually |
occupied during that month.
|
(f) (Blank).
|
(g) Effective January 1, 2006, there is hereby established |
a program of pharmaceutical assistance to the aged and |
disabled, entitled the Illinois Seniors and Disabled Drug |
|
Coverage Program, which shall be administered by the Department |
of Healthcare and Family Services and the Department on Aging |
in accordance with this subsection, to consist of coverage of |
specified prescription drugs on behalf of beneficiaries of the |
program as set forth in this subsection. Notwithstanding any |
provisions of this Act to the contrary, on and after July 1, |
2012, pharmaceutical assistance under this Act shall no longer |
be provided, and on July 1, 2012 the Illinois Senior Citizens |
and Disabled Persons Pharmaceutical Assistance Program shall |
terminate. The following provisions that concern the Illinois |
Senior Citizens and Disabled Persons Pharmaceutical Assistance |
Program shall continue to apply on and after July 1, 2012 to |
the extent necessary to pursue any actions authorized by |
subsection (d) of Section 9 of this Act with respect to acts |
which took place prior to July 1, 2012. |
To become a beneficiary under the program established under |
this subsection, a person must: |
(1) be (i) 65 years of age or older or (ii) disabled; |
and |
(2) be domiciled in this State; and |
(3) enroll with a qualified Medicare Part D |
Prescription Drug Plan if eligible and apply for all |
available subsidies under Medicare Part D; and |
(4) for the 2006 and 2007 claim years, have a maximum |
household income of (i) less than $21,218 for a household |
containing one person, (ii) less than $28,480 for a |
|
household containing 2 persons, or (iii) less than $35,740 |
for a household containing 3 or more persons; and |
(5) for the 2008 claim year, have a maximum household |
income of (i) less than $22,218 for a household containing |
one person, (ii) $29,480 for a household containing 2 |
persons, or (iii) $36,740 for a household containing 3 or |
more persons; and |
(6) for 2009 claim year applications submitted during |
calendar year 2010, have annual household income of less |
than (i) $27,610 for a household containing one person; |
(ii) less than $36,635 for a household containing 2 |
persons; or (iii) less than $45,657 for a household |
containing 3 or more persons; and |
(7) as of September 1, 2011, have a maximum household |
income at or below 200% of the federal poverty level. |
All individuals enrolled as of December 31, 2005, in the |
pharmaceutical assistance program operated pursuant to |
subsection (f) of this Section and all individuals enrolled as |
of December 31, 2005, in the SeniorCare Medicaid waiver program |
operated pursuant to Section 5-5.12a of the Illinois Public Aid |
Code shall be automatically enrolled in the program established |
by this subsection for the first year of operation without the |
need for further application, except that they must apply for |
Medicare Part D and the Low Income Subsidy under Medicare Part |
D. A person enrolled in the pharmaceutical assistance program |
operated pursuant to subsection (f) of this Section as of |
|
December 31, 2005, shall not lose eligibility in future years |
due only to the fact that they have not reached the age of 65. |
To the extent permitted by federal law, the Department may |
act as an authorized representative of a beneficiary in order |
to enroll the beneficiary in a Medicare Part D Prescription |
Drug Plan if the beneficiary has failed to choose a plan and, |
where possible, to enroll beneficiaries in the low-income |
subsidy program under Medicare Part D or assist them in |
enrolling in that program. |
Beneficiaries under the program established under this |
subsection shall be divided into the following 4 eligibility |
groups: |
(A) Eligibility Group 1 shall consist of beneficiaries |
who are not eligible for Medicare Part D coverage and who
|
are: |
(i) disabled and under age 65; or |
(ii) age 65 or older, with incomes over 200% of the |
Federal Poverty Level; or |
(iii) age 65 or older, with incomes at or below |
200% of the Federal Poverty Level and not eligible for |
federally funded means-tested benefits due to |
immigration status. |
(B) Eligibility Group 2 shall consist of beneficiaries |
who are eligible for Medicare Part D coverage. |
(C) Eligibility Group 3 shall consist of beneficiaries |
age 65 or older, with incomes at or below 200% of the |
|
Federal Poverty Level, who are not barred from receiving |
federally funded means-tested benefits due to immigration |
status and are not eligible for Medicare Part D coverage. |
If the State applies and receives federal approval for |
a waiver under Title XIX of the Social Security Act, |
persons in Eligibility Group 3 shall continue to receive |
benefits through the approved waiver, and Eligibility |
Group 3 may be expanded to include disabled persons under |
age 65 with incomes under 200% of the Federal Poverty Level |
who are not eligible for Medicare and who are not barred |
from receiving federally funded means-tested benefits due |
to immigration status. |
(D) Eligibility Group 4 shall consist of beneficiaries |
who are otherwise described in Eligibility Group 2 who have |
a diagnosis of HIV or AIDS.
|
The program established under this subsection shall cover |
the cost of covered prescription drugs in excess of the |
beneficiary cost-sharing amounts set forth in this paragraph |
that are not covered by Medicare. The Department of Healthcare |
and Family Services may establish by emergency rule changes in |
cost-sharing necessary to conform the cost of the program to |
the amounts appropriated for State fiscal year 2012 and future |
fiscal years except that the 24-month limitation on the |
adoption of emergency rules and the provisions of Sections |
5-115 and 5-125 of the Illinois Administrative Procedure Act |
shall not apply to rules adopted under this subsection (g). The |
|
adoption of emergency rules authorized by this subsection (g) |
shall be deemed to be necessary for the public interest, |
safety, and welfare.
|
For purposes of the program established under this |
subsection, the term "covered prescription drug" has the |
following meanings: |
For Eligibility Group 1, "covered prescription drug" |
means: (1) any cardiovascular agent or drug; (2) any |
insulin or other prescription drug used in the treatment of |
diabetes, including syringe and needles used to administer |
the insulin; (3) any prescription drug used in the |
treatment of arthritis; (4) any prescription drug used in |
the treatment of cancer; (5) any prescription drug used in |
the treatment of Alzheimer's disease; (6) any prescription |
drug used in the treatment of Parkinson's disease; (7) any |
prescription drug used in the treatment of glaucoma; (8) |
any prescription drug used in the treatment of lung disease |
and smoking-related illnesses; (9) any prescription drug |
used in the treatment of osteoporosis; and (10) any |
prescription drug used in the treatment of multiple |
sclerosis. The Department may add additional therapeutic |
classes by rule. The Department may adopt a preferred drug |
list within any of the classes of drugs described in items |
(1) through (10) of this paragraph. The specific drugs or |
therapeutic classes of covered prescription drugs shall be |
indicated by rule. |
|
For Eligibility Group 2, "covered prescription drug" |
means those drugs covered by the Medicare Part D |
Prescription Drug Plan in which the beneficiary is |
enrolled. |
For Eligibility Group 3, "covered prescription drug" |
means those drugs covered by the Medical Assistance Program |
under Article V of the Illinois Public Aid Code. |
For Eligibility Group 4, "covered prescription drug" |
means those drugs covered by the Medicare Part D |
Prescription Drug Plan in which the beneficiary is |
enrolled. |
Any person otherwise eligible for pharmaceutical |
assistance under this subsection whose covered drugs are |
covered by any public program is ineligible for assistance |
under this subsection to the extent that the cost of those |
drugs is covered by the other program. |
The Department of Healthcare and Family Services shall |
establish by rule the methods by which it will provide for the |
coverage called for in this subsection. Those methods may |
include direct reimbursement to pharmacies or the payment of a |
capitated amount to Medicare Part D Prescription Drug Plans. |
For a pharmacy to be reimbursed under the program |
established under this subsection, it must comply with rules |
adopted by the Department of Healthcare and Family Services |
regarding coordination of benefits with Medicare Part D |
Prescription Drug Plans. A pharmacy may not charge a |
|
Medicare-enrolled beneficiary of the program established under |
this subsection more for a covered prescription drug than the |
appropriate Medicare cost-sharing less any payment from or on |
behalf of the Department of Healthcare and Family Services. |
The Department of Healthcare and Family Services or the |
Department on Aging, as appropriate, may adopt rules regarding |
applications, counting of income, proof of Medicare status, |
mandatory generic policies, and pharmacy reimbursement rates |
and any other rules necessary for the cost-efficient operation |
of the program established under this subsection. |
(h) A qualified individual is not entitled to duplicate
|
benefits in a coverage period as a result of the changes made
|
by this amendatory Act of the 96th General Assembly.
|
(Source: P.A. 96-804, eff. 1-1-10; 97-74, eff. 6-30-11; 97-333, |
eff. 8-12-11.)
|
(320 ILCS 25/4.05) |
Sec. 4.05. Application. |
(a) The Department on Aging shall establish the content,
|
required eligibility and identification information, use of
|
social security numbers, and manner of applying for benefits in |
a simplified format
under this Act , including claims filed for
|
new or renewed prescription drug benefits . |
(b) An application may be filed on paper or over the |
Internet to enable persons to apply separately
or for both a |
property tax relief grant and pharmaceutical
assistance on the |
|
same application. An application may also
enable persons to |
apply for other State or federal programs
that provide medical |
or pharmaceutical assistance or other
benefits, as determined |
by the Department on Aging in
conjunction with the Department |
of Healthcare and Family
Services . |
(c) Applications must be filed during the time period
|
prescribed by the Department.
|
(Source: P.A. 96-804, eff. 1-1-10.)
|
(320 ILCS 25/5) (from Ch. 67 1/2, par. 405)
|
Sec. 5. Procedure.
|
(a) In general. Claims must be filed after January 1, on |
forms prescribed
by the Department. No claim may be filed more |
than one year after December 31
of the year for which the claim |
is filed. The pharmaceutical assistance identification
card |
provided for in subsection (f) of Section 4 shall be valid for |
a period determined by the Department of Healthcare and Family |
Services.
|
(b) Claim is Personal. The right to file a claim under this |
Act
shall be personal to the claimant and shall not survive his |
death, but
such right may be exercised on behalf of a claimant |
by his legal
guardian or attorney-in-fact. If a claimant dies |
after having filed a
timely claim, the amount thereof shall be |
disbursed to his surviving spouse
or, if no spouse survives, to |
his surviving dependent minor children in
equal parts, provided |
the spouse or child, as the case may be, resided with
the |
|
claimant at the time he filed his claim. If at the time of |
disbursement
neither the claimant nor his spouse is surviving, |
and no dependent minor
children of the claimant are surviving |
the amount of the claim shall
escheat to the State.
|
(c) One claim per household. Only one member of a household |
may file
a claim under this Act in any calendar year; where |
both members of a
household are otherwise entitled to claim a |
grant under this Act, they
must agree as to which of them will |
file a claim for that year.
|
(d) (Blank).
|
(e) Pharmaceutical Assistance Procedures.
Prior to July 1, |
2012, the The Department of Healthcare and Family Services |
shall determine eligibility for pharmaceutical assistance |
using
the applicant's current income. The Department shall |
determine a person's
current income in the manner provided by |
|